Healthcare Provider Details

I. General information

NPI: 1215123047
Provider Name (Legal Business Name): JACKSON COOPER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2007
Last Update Date: 09/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 MOODY ST
SACO ME
04072-1536
US

IV. Provider business mailing address

33 OBRION ST
PORTLAND ME
04101-4411
US

V. Phone/Fax

Practice location:
  • Phone: 800-434-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC6541
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: