Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 106S00000X | Behavior Technician |
NPI | 1003336512 |
---|---|
Provider Name | Jennifer Coppedge |
First Address | Lake City, FL 32055-4883 |
Second Address | Lake City, FL 32055-4883 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/06/2017 |
Last Update Date | 26/06/2017 |