Healthcare Provider Details

I. General information

NPI: 1356457576
Provider Name (Legal Business Name): JASON ANDRE COOPER ATC, PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 02/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 EAST MAIN ST.
SENATOBIA MS
38668
US

IV. Provider business mailing address

20 S. MAIN STREET
WATER VALLEY MS
38965
US

V. Phone/Fax

Practice location:
  • Phone: 662-560-0602
  • Fax: 662-560-0603
Mailing address:
  • Phone: 662-473-3400
  • Fax: 662-473-4389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT0326
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: