Provider Demographics
NPI:1487103404
Name:COPPAGE, JASON (CMT)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:COPPAGE
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12190 RICHLAND DR
Mailing Address - Street 2:
Mailing Address - City:CATHARPIN
Mailing Address - State:VA
Mailing Address - Zip Code:20143-1103
Mailing Address - Country:US
Mailing Address - Phone:571-232-7093
Mailing Address - Fax:
Practice Address - Street 1:12190 RICHLAND DR
Practice Address - Street 2:
Practice Address - City:CATHARPIN
Practice Address - State:VA
Practice Address - Zip Code:20143-1103
Practice Address - Country:US
Practice Address - Phone:571-232-7093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019008131225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist