MEDICARE: CONSTANCE COOPER LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SW8901	FL

General Provider Information

NPI Number	:	1033397096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONSTANCE COOPER LCSW

Provider Business Mailing Address
First Line	:	4350 HIAWATHA ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-5958
Country	:	US
Telephone Number	:	904-233-8690
Fax Number	:	904-448-0349

Provider Business Practice Location Address
First Line	:	6261 DUPONT STATION CT
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32217-2567
Country	:	US
Telephone Number	:	904-394-5761
Fax Number	:	904-448-0349

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/01/2008
Last Update Date	:	08/01/2008

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