Provider Demographics
NPI:1912905837
Name:COOPER, JOHN A (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:COOPER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:5668 S REX RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-3829
Mailing Address - Country:US
Mailing Address - Phone:901-681-0851
Mailing Address - Fax:901-681-0872
Practice Address - Street 1:5668 S REX RD
Practice Address - Street 2:SUITE 102
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-3829
Practice Address - Country:US
Practice Address - Phone:901-681-0851
Practice Address - Fax:901-681-0872
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP659103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3680078Medicare UPIN
TN3680078Medicare ID - Type UnspecifiedMEDICARE