MEDICARE: CONSTANCE L COOPER PA

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	:	1508020140
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONSTANCE L COOPER PA

Provider Business Mailing Address
First Line	:	4040 WOODCOCK DR
Second Line	:	BUILDING 2200, SUITE 232
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-2720
Country	:	US
Telephone Number	:	904-233-8690
Fax Number	:

Provider Business Practice Location Address
First Line	:	4040 WOODCOCK DR
Second Line	:	BUILDING 2200, SUITE 232
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-2720
Country	:	US
Telephone Number	:	904-233-8690
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CONSTANCE L COOPER
Credential	:	LCSW
Telephone Number	:	904-233-8690

Provider Enumeration Date	:	07/14/2008
Last Update Date	:	07/15/2008

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