Healthcare Provider Details

I. General information

NPI: 1588725204
Provider Name (Legal Business Name): JORDAN TODD COOPER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 09/23/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 N JAMES ST
JACKSONVILLE AR
72076-4018
US

IV. Provider business mailing address

308 N JAMES ST
JACKSONVILLE AR
72076-4018
US

V. Phone/Fax

Practice location:
  • Phone: 501-982-7547
  • Fax: 501-985-8421
Mailing address:
  • Phone: 501-982-7547
  • Fax: 501-985-8421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3535
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3565
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: