Provider Demographics
NPI:1689486458
Name:COOPER, JACEY
Entity type:Individual
Prefix:
First Name:JACEY
Middle Name:
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 1:202 KESWICK RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40769-6478
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:202 KESWICK RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:KY
Practice Address - Zip Code:40769-6478
Practice Address - Country:US
Practice Address - Phone:606-406-9883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-21
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program