Healthcare Provider Details

I. General information

NPI: 1164412474
Provider Name (Legal Business Name): JESSIE LEE COPELAND JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 09/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 DOCTORS DR
CELINA TN
38551
US

IV. Provider business mailing address

PO BOX 388
CELINA TN
38551-0388
US

V. Phone/Fax

Practice location:
  • Phone: 931-243-3860
  • Fax: 931-243-4607
Mailing address:
  • Phone: 931-243-3860
  • Fax: 931-243-4607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number30843
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD30843
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License NumberMD30843
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number30843
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: