MEDICARE: JERRICA DANIELLE 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	164W00000X	Licensed Practical Nurse	330509	NY
2	163W00000X	Registered Nurse	N29835	NY

General Provider Information

NPI Number	:	1912412859
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERRICA DANIELLE COOPER

Provider Business Mailing Address
First Line	:	PO BOX 30022
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14603-3022
Country	:	US
Telephone Number	:	585-285-1582
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 PARKSIDE AVE
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14609-4908
Country	:	US
Telephone Number	:	585-285-1582
Fax Number	:

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

Provider Enumeration Date	:	12/13/2017
Last Update Date	:	06/12/2026

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