Healthcare Provider Details

I. General information

NPI: 1083932404
Provider Name (Legal Business Name): JACQUELYN N COPELAND MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2010
Last Update Date: 11/17/2022
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE RADIOLOGY DEPT
HACKENSACK NJ
07601-1915
US

IV. Provider business mailing address

130 KINDERKAMACK RD STE 200
RIVER EDGE NJ
07661-1931
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-2200
  • Fax:
Mailing address:
  • Phone: 201-488-2660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25MA09888200
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: