Provider Demographics
NPI:1487730214
Name:COOPER, JENNIE L (CRNA)
Entity type:Individual
Prefix:MS
First Name:JENNIE
Middle Name:L
Last Name:COOPER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13728 SPRINGDALE DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21029-1353
Mailing Address - Country:US
Mailing Address - Phone:410-531-1180
Mailing Address - Fax:301-854-2214
Practice Address - Street 1:1838 GREENE TREE RD
Practice Address - Street 2:SUITE 400
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21208-6391
Practice Address - Country:US
Practice Address - Phone:410-531-1180
Practice Address - Fax:301-854-2214
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR041214207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR09118Medicare UPIN