MEDICARE: ALICIA JEAN COOPER PMHNP-BC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	0024191839	VA

General Provider Information

NPI Number	:	1770303737
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALICIA JEAN COOPER PMHNP-BC

Provider Business Mailing Address
First Line	:	3501 STORM BIRD LOOP
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23453-2257
Country	:	US
Telephone Number	:	757-619-4534
Fax Number	:

Provider Business Practice Location Address
First Line	:	5265 PROVIDENCE RD STE 500
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-4210
Country	:	US
Telephone Number	:	757-467-9500
Fax Number	:	757-467-9560

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

Provider Enumeration Date	:	10/15/2024
Last Update Date	:	06/17/2026

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