Provider Demographics
NPI:1801355680
Name:COPELAND, JERRY ALLEN
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:ALLEN
Last Name:COPELAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:437 W PARKER ST
Mailing Address - Street 2:
Mailing Address - City:BAXLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31513-0605
Mailing Address - Country:US
Mailing Address - Phone:912-705-0858
Mailing Address - Fax:912-705-6423
Practice Address - Street 1:437 W PARKER ST
Practice Address - Street 2:
Practice Address - City:BAXLEY
Practice Address - State:GA
Practice Address - Zip Code:31513-0605
Practice Address - Country:US
Practice Address - Phone:912-705-0858
Practice Address - Fax:912-705-6423
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-19
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
GA101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor