1639107469 NPI number — JON COOPER P.T.

Table of content: JON COOPER P.T. (NPI 1639107469)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639107469 NPI number — JON COOPER P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COOPER
Provider First Name:
JON
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639107469
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
139 FOX RD
Provider Second Line Business Mailing Address:
SUITE 111
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37922-3472
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-539-2606
Provider Business Mailing Address Fax Number:
865-539-2446

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
139 FOX RD
Provider Second Line Business Practice Location Address:
SUITE 111
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37922-3472
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-539-2606
Provider Business Practice Location Address Fax Number:
865-539-2446
Provider Enumeration Date:
06/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT6034 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3659122 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4082601 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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