Provider Demographics
NPI:1548791312
Name:COOPER, JESSICA LYN (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYN
Last Name:COOPER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3240 AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-6320
Mailing Address - Country:US
Mailing Address - Phone:770-860-1133
Mailing Address - Fax:770-860-1941
Practice Address - Street 1:3240 AVALON BLVD
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-6320
Practice Address - Country:US
Practice Address - Phone:770-860-1133
Practice Address - Fax:770-860-1941
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-23
Last Update Date:2025-08-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
GA89506207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty