Provider Demographics
NPI:1073338620
Name:COOPER, JAN
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 E 450 S STE A
Mailing Address - Street 2:
Mailing Address - City:WHITESTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46075-8404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15033 W 102ND AVE
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-7752
Practice Address - Country:US
Practice Address - Phone:219-644-7818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26023843A1835X0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835X0200XPharmacy Service ProvidersPharmacistOncology