Basic Information
| Provider Information | |||||||||
| NPI: | 1205104379 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COPELAND | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2526 | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648032526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173587728 | ||||||||
| FaxNumber: | 4173470293 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901 E 32ND ST | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648043312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173477567 | ||||||||
| FaxNumber: | 4173470293 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2011 | ||||||||
| LastUpdateDate: | 12/27/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 2012033727 | MO | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 201087620A | 05 | KS | MEDICAID | 1205104379 | 05 | MO | MEDICAID |