Provider Demographics
NPI:1255511572
Name:COOPER, JACK MARSHALL (MD)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:MARSHALL
Last Name:COOPER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 BROWN SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-7005
Mailing Address - Country:US
Mailing Address - Phone:334-747-4159
Mailing Address - Fax:
Practice Address - Street 1:470 TAYLOR RD
Practice Address - Street 2:SUITE 202
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-3563
Practice Address - Country:US
Practice Address - Phone:334-244-6773
Practice Address - Fax:334-244-4234
Is Sole Proprietor?:No
Enumeration Date:2007-11-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-00248208600000X
AL32228208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5920296Medicaid
AL149171Medicaid
NCNC6449AMedicare PIN
NC5920296Medicaid