Provider Demographics
NPI:1699730614
Name:COOPER-HENSON, JACLYN KELLY (DC)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:KELLY
Last Name:COOPER-HENSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 MERCHANT ST
Mailing Address - Street 2:PO BOX 861
Mailing Address - City:COLUMBIA
Mailing Address - State:KY
Mailing Address - Zip Code:42728
Mailing Address - Country:US
Mailing Address - Phone:270-384-5772
Mailing Address - Fax:270-380-1778
Practice Address - Street 1:117 MERCHANT ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:KY
Practice Address - Zip Code:42728
Practice Address - Country:US
Practice Address - Phone:270-384-5772
Practice Address - Fax:270-380-1778
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4655111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY85001881Medicaid
U88035Medicare UPIN
6098201Medicare ID - Type Unspecified