Basic Information
Provider Information | |||||||||
NPI: | 1386911345 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COOPER | ||||||||
FirstName: | JEANNE | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMSW ACSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9186 RIDGEFIELD DR | ||||||||
Address2: |   | ||||||||
City: | BRIGHTON | ||||||||
State: | MI | ||||||||
PostalCode: | 481144982 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5178815425 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 120 FLINT RD | ||||||||
Address2: |   | ||||||||
City: | BRIGHTON | ||||||||
State: | MI | ||||||||
PostalCode: | 481161112 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8104947180 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/18/2011 | ||||||||
LastUpdateDate: | 11/18/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801077746 | MI | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 1041C0700X | 6801077746 | MI | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.