Healthcare Provider Details

I. General information

NPI: 1386091403
Provider Name (Legal Business Name): JESSICA COOPER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2016
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11653 CENTRAL PKWY
JACKSONVILLE FL
32224-2710
US

IV. Provider business mailing address

11653 CENTRAL PKWY
JACKSONVILLE FL
32224-2710
US

V. Phone/Fax

Practice location:
  • Phone: 904-300-3014
  • Fax:
Mailing address:
  • Phone: 904-300-3014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-90203
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: