Provider Demographics
NPI:1497454714
Name:COOLEY, MAKENNA JANE
Entity Type:Individual
Prefix:
First Name:MAKENNA
Middle Name:JANE
Last Name:COOLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14500 N 46TH ST UNIT 402-C
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-3154
Mailing Address - Country:US
Mailing Address - Phone:920-492-9553
Mailing Address - Fax:
Practice Address - Street 1:4518 3RD AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33711-1018
Practice Address - Country:US
Practice Address - Phone:727-417-3269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-24
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-259878106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician