Provider Demographics
NPI:1558776880
Name:COOLIDGE, JENELLE (MS)
Entity Type:Individual
Prefix:
First Name:JENELLE
Middle Name:
Last Name:COOLIDGE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:JENELLE
Other - Middle Name:PATRICIA
Other - Last Name:GONZALEZ, BANASZAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:6645 VINELAND RD STE 270
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-7840
Mailing Address - Country:US
Mailing Address - Phone:253-310-3910
Mailing Address - Fax:
Practice Address - Street 1:6644 VINELAND RD
Practice Address - Street 2:SUITE 270
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819
Practice Address - Country:US
Practice Address - Phone:253-310-3910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-25
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH19534101YM0800X
FLMH21266101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health