Provider Demographics
NPI:1215903984
Name:MCCONNELL-COPPLOE, JEAN A (PT)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:A
Last Name:MCCONNELL-COPPLOE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 BOARDMAN CANFIELD RD
Mailing Address - Street 2:BLDG F, UNIT 2
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512
Mailing Address - Country:US
Mailing Address - Phone:330-480-9362
Mailing Address - Fax:330-480-9407
Practice Address - Street 1:755 BOARDMAN CANFIELD RD
Practice Address - Street 2:BLDG F, UNIT 2
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512
Practice Address - Country:US
Practice Address - Phone:330-480-9362
Practice Address - Fax:330-480-9407
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT10021174400000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2384647Medicaid
OH2384647Medicaid
OH9336281Medicare ID - Type UnspecifiedGROUP NUMBER