Provider Demographics
NPI:1366711442
Name:COOPER, EARNEST JR
Entity type:Individual
Prefix:MR
First Name:EARNEST
Middle Name:
Last Name:COOPER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 E 1800 N
Mailing Address - Street 2:APT2
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-1790
Mailing Address - Country:US
Mailing Address - Phone:435-881-6247
Mailing Address - Fax:
Practice Address - Street 1:166 E 1800 N
Practice Address - Street 2:APT2
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1790
Practice Address - Country:US
Practice Address - Phone:435-881-6247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency