Healthcare Provider Details

I. General information

NPI: 1831691948
Provider Name (Legal Business Name): REESE JEREL COOPER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2018
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 SAINT ELIZABETH BLVD STE 4000
O FALLON IL
62269-1284
US

IV. Provider business mailing address

3 SAINT ELIZABETH BLVD STE 4000
O FALLON IL
62269-1284
US

V. Phone/Fax

Practice location:
  • Phone: 618-256-9355
  • Fax: 618-206-2332
Mailing address:
  • Phone: 618-256-9355
  • Fax: 618-206-2332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7811204-2402
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: