Provider Demographics
NPI:1972843068
Name:COOLEY, JENNIE C (CAODC)
Entity Type:Individual
Prefix:MS
First Name:JENNIE
Middle Name:C
Last Name:COOLEY
Suffix:
Gender:F
Credentials:CAODC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1803 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1047
Mailing Address - Country:US
Mailing Address - Phone:559-268-6475
Mailing Address - Fax:559-268-6967
Practice Address - Street 1:1803 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721-1047
Practice Address - Country:US
Practice Address - Phone:559-268-6475
Practice Address - Fax:559-268-6967
Is Sole Proprietor?:No
Enumeration Date:2013-02-26
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACADDTP 1437101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)