MEDICARE: MR. JESSIE LEE COPELAND JR. M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RA0000X	Adolescent Medicine (Internal Medicine) Physician	MD30843	TN
2	207P00000X	Emergency Medicine Physician	30843	TN
3	207R00000X	Internal Medicine Physician	MD30843	TN
4	208M00000X	Hospitalist Physician	30843	TN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	P00162052	OTHER	TN	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	141913142	OTHER	TN	TAX ID

General Provider Information

NPI Number	:	1164412474
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JESSIE LEE COPELAND JR. M.D.

Provider Business Mailing Address
First Line	:	PO BOX 388
Second Line	:
City	:	CELINA
State	:	TN
Zip	:	38551-0388
Country	:	US
Telephone Number	:	931-243-3860
Fax Number	:	931-243-4607

Provider Business Practice Location Address
First Line	:	110 DOCTORS DR
Second Line	:
City	:	CELINA
State	:	TN
Zip	:	38551
Country	:	US
Telephone Number	:	931-243-3860
Fax Number	:	931-243-4607

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/27/2005
Last Update Date	:	09/19/2019

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Directions to “ MR. JESSIE LEE COPELAND JR. M.D.” Practice Location

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