Provider Demographics
NPI:1326217480
Name:COPE, JACKIE (LMSW)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:COPE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1526
Mailing Address - Street 2:
Mailing Address - City:TULAROSA
Mailing Address - State:NM
Mailing Address - Zip Code:88352-1526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1221 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:TULAROSA
Practice Address - State:NM
Practice Address - Zip Code:88352-9334
Practice Address - Country:US
Practice Address - Phone:505-491-2224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-22
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-05839104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker