Provider Demographics
NPI:1841250198
Name:COPPOCK, JEFFREY DOUGLAS (MS PT)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:DOUGLAS
Last Name:COPPOCK
Suffix:
Gender:M
Credentials:MS PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9778 SPRINGHILL FARMS DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDER
Mailing Address - State:AR
Mailing Address - Zip Code:72002-8998
Mailing Address - Country:US
Mailing Address - Phone:501-588-7674
Mailing Address - Fax:
Practice Address - Street 1:200 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72022-3424
Practice Address - Country:US
Practice Address - Phone:501-847-5660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT2660225100000X
ARPTA2715225200000X
AROTA936224Z00000X
AROTR825225X00000X
ARPT2370225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR211208721Medicaid
AR139676721Medicaid
AR1619411721Medicaid
AR197090795Medicaid
AR126978721Medicaid
AR149815721Medicaid
AR5U673OtherBCBS