Healthcare Provider Details

I. General information

NPI: 1447965900
Provider Name (Legal Business Name): JASMINE COOPER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2023
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 E GENERAL STEWART WAY STE 103
HINESVILLE GA
31313-2636
US

IV. Provider business mailing address

740 E GENERAL STEWART WAY STE 103
HINESVILLE GA
31313-2636
US

V. Phone/Fax

Practice location:
  • Phone: 877-321-2899
  • Fax:
Mailing address:
  • Phone: 877-321-2899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-254252
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: