Healthcare Provider Details

I. General information

NPI: 1508020140
Provider Name (Legal Business Name): CONSTANCE L COOPER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2008
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4040 WOODCOCK DR BUILDING 2200, SUITE 232
JACKSONVILLE FL
32207-2720
US

IV. Provider business mailing address

4040 WOODCOCK DR BUILDING 2200, SUITE 232
JACKSONVILLE FL
32207-2720
US

V. Phone/Fax

Practice location:
  • Phone: 904-233-8690
  • Fax:
Mailing address:
  • Phone: 904-233-8690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW8901
License Number StateFL

VIII. Authorized Official

Name: CONSTANCE L COOPER
Title or Position: OWNER
Credential: LCSW
Phone: 904-233-8690