Provider Demographics
NPI:1417540063
Name:COOLEY, JODY (PTA)
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:COOLEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 LONG AVE
Mailing Address - Street 2:
Mailing Address - City:ELLSINORE
Mailing Address - State:MO
Mailing Address - Zip Code:63937-8217
Mailing Address - Country:US
Mailing Address - Phone:573-714-1033
Mailing Address - Fax:
Practice Address - Street 1:8477 NORTH ST
Practice Address - Street 2:
Practice Address - City:BIRCH TREE
Practice Address - State:MO
Practice Address - Zip Code:65438-8887
Practice Address - Country:US
Practice Address - Phone:573-292-3212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-15
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2017012202OtherMISSOURI STATE BOARD OF REGISTRATION FOR THE HEALING ARTS