Provider Demographics
NPI:1306170220
Name:KOPACH, JENNIFER LYNN (PT, MS)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LYNN
Last Name:KOPACH
Suffix:
Gender:F
Credentials:PT, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4557 WENDEN LN
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-5696
Mailing Address - Country:US
Mailing Address - Phone:917-334-9108
Mailing Address - Fax:
Practice Address - Street 1:3000 JOHNSON FERRY RD STE 110
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062
Practice Address - Country:US
Practice Address - Phone:917-334-9108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-24
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA010961225100000X
NY019712225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist