Provider Demographics
NPI:1912736083
Name:COOPER, JASON GEORGE
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:GEORGE
Last Name:COOPER
Suffix:
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 1:8835 S OAK PARK DR APT 12
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-3814
Mailing Address - Country:US
Mailing Address - Phone:414-881-5976
Mailing Address - Fax:
Practice Address - Street 1:5319 S 108TH ST # 11
Practice Address - Street 2:
Practice Address - City:HALES CORNERS
Practice Address - State:WI
Practice Address - Zip Code:53130-1332
Practice Address - Country:US
Practice Address - Phone:414-881-5976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10683-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist