=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912412859
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JERRICA COOPER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2017
-----------------------------------------------------
Last Update Date | 12/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 69 HILLENDALE ST
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14619-1609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-285-1582
-----------------------------------------------------
Fax | 585-285-1582
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 30093
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14603-3093
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-285-1582
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 330509
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------