Provider Demographics
NPI:1235294935
Name:COOPER, JAN LOUISE (OD, FAAO)
Entity type:Individual
Prefix:DR
First Name:JAN
Middle Name:LOUISE
Last Name:COOPER
Suffix:
Gender:F
Credentials:OD, FAAO
Other - Prefix:DR
Other - First Name:JAN
Other - Middle Name:LOUISE
Other - Last Name:COOPER HAGMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD, FAAO
Mailing Address - Street 1:101 CHANDLER W
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:CA
Mailing Address - Zip Code:92346-5482
Mailing Address - Country:US
Mailing Address - Phone:909-864-0987
Mailing Address - Fax:909-864-0876
Practice Address - Street 1:3693 HIGHLAND AVE
Practice Address - Street 2:SUITE D
Practice Address - City:HIGHLAND
Practice Address - State:CA
Practice Address - Zip Code:92346-2609
Practice Address - Country:US
Practice Address - Phone:909-425-2020
Practice Address - Fax:909-425-2237
Is Sole Proprietor?:No
Enumeration Date:2006-12-25
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8696T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0086960Medicaid
CA7053419OtherMEDICAID PIN
CASD0086960Medicaid
CA7053419OtherMEDICAID PIN