MEDICARE: JACOB COOPER

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1043016488
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB COOPER

Provider Business Mailing Address
First Line	:	12122 S INDIANA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60628-6737
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12122 S INDIANA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60628-6737
Country	:	US
Telephone Number	:	847-890-8548
Fax Number	:

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

Provider Enumeration Date	:	02/24/2025
Last Update Date	:	02/24/2025

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Directions to “ JACOB COOPER ” Practice Location

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