Healthcare Provider Details

I. General information

NPI: 1154502631
Provider Name (Legal Business Name): JENNIFER R. COOPER, PHD, PSYCHOLOGICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2007
Last Update Date: 11/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

833 NW BUCHANAN AVE STE 10
CORVALLIS OR
97330-6217
US

IV. Provider business mailing address

833 NW BUCHANAN AVE STE 10
CORVALLIS OR
97330-6217
US

V. Phone/Fax

Practice location:
  • Phone: 541-207-3937
  • Fax: 541-207-3623
Mailing address:
  • Phone: 541-207-3937
  • Fax: 541-207-3623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number1835
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1835
License Number StateOR

VIII. Authorized Official

Name: DR. JENNIFER R COOPER
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PHD
Phone: 541-207-3937