Healthcare Provider Details

I. General information

NPI: 1780141630
Provider Name (Legal Business Name): JEROME ANTHONY COPPAGE JR. BCBA 1-21-55996
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2019
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30073 VIA AMANTE
MENIFEE CA
92584-8910
US

IV. Provider business mailing address

30073 VIA AMANTE
MENIFEE CA
92584-8910
US

V. Phone/Fax

Practice location:
  • Phone: 619-895-4615
  • Fax:
Mailing address:
  • Phone: 619-895-4615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-16-4282-36534
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-55996
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: