Provider Demographics
NPI:1821453838
Name:COOLEY, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:COOLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 GLENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-7889
Mailing Address - Country:US
Mailing Address - Phone:530-921-6315
Mailing Address - Fax:
Practice Address - Street 1:237 GLENWOOD RD
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-7889
Practice Address - Country:US
Practice Address - Phone:530-921-6315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-17
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker