Provider Demographics
NPI:1962878108
Name:COPELIN, JASON (PT)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:COPELIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1331 LAKE DR SE SUITE 105
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-1674
Mailing Address - Country:US
Mailing Address - Phone:616-248-9842
Mailing Address - Fax:616-248-9848
Practice Address - Street 1:1331 LAKE DR SE STE 105
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-1674
Practice Address - Country:US
Practice Address - Phone:269-838-0369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501017279225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist