Provider Demographics
NPI:1588725204
Name:COOPER, JORDAN TODD (DDS)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:TODD
Last Name:COOPER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 N JAMES ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72076-4018
Mailing Address - Country:US
Mailing Address - Phone:501-982-7547
Mailing Address - Fax:501-985-8421
Practice Address - Street 1:308 N JAMES ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-4018
Practice Address - Country:US
Practice Address - Phone:501-982-7547
Practice Address - Fax:501-985-8421
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR35651223G0001X
AR3535122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y893OtherBLUE CROSS BLUE SHIELD
AR164868608Medicaid
AR1874975OtherUNITED CONCORDIA