Healthcare Provider Details

I. General information

NPI: 1780440727
Provider Name (Legal Business Name): JAMES JEROD COOPER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2024
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 E 29TH ST N
WICHITA KS
67226-2169
US

IV. Provider business mailing address

7018 E MAINSGATE CT
WICHITA KS
67226-1631
US

V. Phone/Fax

Practice location:
  • Phone: 316-634-8710
  • Fax:
Mailing address:
  • Phone: 316-217-2116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: