Basic Information
| Provider Information | |||||||||
| NPI: | 1063901882 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOPER | ||||||||
| FirstName: | SHANNA | ||||||||
| MiddleName: | |||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 SW 5TH AVE STE 500 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972015537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666176855 | ||||||||
| FaxNumber: | 5033468015 | ||||||||
| Practice Location | |||||||||
| Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034946176 | ||||||||
| FaxNumber: | 5034946152 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2018 | ||||||||
| LastUpdateDate: | 10/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 31004 | CA | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103T00000X | 31004 | CA | N | Behavioral Health & Social Service Providers | Psychologist | 103G00000X | 3482 | OR | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
No ID Information.