Healthcare Provider Details

I. General information

NPI: 1417017252
Provider Name (Legal Business Name): JEANINE COPPERSTONE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 OFFICERS ROW STE A
VANCOUVER WA
98661-3847
US

IV. Provider business mailing address

800 OFFICERS ROW STE A
VANCOUVER WA
98661-3847
US

V. Phone/Fax

Practice location:
  • Phone: 503-869-1594
  • Fax:
Mailing address:
  • Phone: 503-867-9159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPY60919826
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: