Healthcare Provider Details

I. General information

NPI: 1417663949
Provider Name (Legal Business Name): JAANA COOGAN PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2023
Last Update Date: 01/27/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 CLYDE MORRIS BLVD STE 300
ORMOND BEACH FL
32174-8144
US

IV. Provider business mailing address

4310 METRO PKWY STE 205
FORT MYERS FL
33916-9416
US

V. Phone/Fax

Practice location:
  • Phone: 386-262-1627
  • Fax: 386-262-1628
Mailing address:
  • Phone: 239-236-8784
  • Fax: 239-790-2624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11023125
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: