Healthcare Provider Details

I. General information

NPI: 1225650708
Provider Name (Legal Business Name): JEFFREY THOMAS COPELAND
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2020
Last Update Date: 05/07/2020
Certification Date: 05/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9990 COUNTY FARM RD STE 5
RIVERSIDE CA
92503-3542
US

IV. Provider business mailing address

23905 CLINTON KEITH RD # 114-211
WILDOMAR CA
92595-7897
US

V. Phone/Fax

Practice location:
  • Phone: 951-509-8339
  • Fax:
Mailing address:
  • Phone: 951-259-4183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: