Provider Demographics
NPI:1902472145
Name:COONEY, JILL MARIE
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE
Last Name:COONEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:MARIE
Other - Last Name:STOWE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2748 N EDDY DR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-0702
Mailing Address - Country:US
Mailing Address - Phone:928-600-2190
Mailing Address - Fax:
Practice Address - Street 1:2748 N EDDY DR
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-0702
Practice Address - Country:US
Practice Address - Phone:928-600-2190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-28
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRBT-21-168194106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician