Healthcare Provider Details

I. General information

NPI: 1689486458
Provider Name (Legal Business Name): JACEY COOPER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2025
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 N HIGHWAY 25 W STE 100
WILLIAMSBURG KY
40769-1576
US

IV. Provider business mailing address

131 KESWICK RD
WILLIAMSBURG KY
40769-9444
US

V. Phone/Fax

Practice location:
  • Phone: 606-549-2930
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: