=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174246128
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIA JASMINE COPELAND-BROCK APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2022
-----------------------------------------------------
Last Update Date | 06/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 165 MAIN ST
-----------------------------------------------------
City | MEDWAY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02053-1584
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-321-3210
-----------------------------------------------------
Fax | 508-321-3210
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 417 LIBERTY ST
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01104-3736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-246-9675
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | RN2313693
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | RN2313693
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------