Provider Demographics
NPI:1801677372
Name:COOPER, JESSICA ELAYNE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELAYNE
Last Name:COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6521 HIDDEN FIELDS CT
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-9101
Mailing Address - Country:US
Mailing Address - Phone:515-491-8512
Mailing Address - Fax:
Practice Address - Street 1:805 N 6TH ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-4113
Practice Address - Country:US
Practice Address - Phone:920-457-8867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7648-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health