Provider Demographics
NPI:1811556285
Name:COOL, JENNICA
Entity Type:Individual
Prefix:
First Name:JENNICA
Middle Name:
Last Name:COOL
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 1:10123 HASTINGS RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48815-9754
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10123 HASTINGS RD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:MI
Practice Address - Zip Code:48815-9754
Practice Address - Country:US
Practice Address - Phone:616-427-2503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703080567164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse