Healthcare Provider Details

I. General information

NPI: 1083857445
Provider Name (Legal Business Name): JACK ALAN COPLEY DMIN, LMFT, IMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2009
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1714 HIGHLAND AVE
CARROLLTON KY
41008-8775
US

IV. Provider business mailing address

3927 EILEEN DR
CINCINNATI OH
45209-2014
US

V. Phone/Fax

Practice location:
  • Phone: 502-732-9331
  • Fax:
Mailing address:
  • Phone: 304-205-0695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number08-029
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: