Healthcare Provider Details

I. General information

NPI: 1326538315
Provider Name (Legal Business Name): JASON BRIAN COPELAND FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1017 W BEACON ST
PHILADELPHIA MS
39350-3218
US

IV. Provider business mailing address

4443 MARS HILL RD
PHILADELPHIA MS
39350-1918
US

V. Phone/Fax

Practice location:
  • Phone: 769-200-0730
  • Fax:
Mailing address:
  • Phone: 601-479-9760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number902488
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: