Healthcare Provider Details

I. General information

NPI: 1184185563
Provider Name (Legal Business Name): JILL COON PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 03/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 EDISON AVE NW
GRAND RAPIDS MI
49504-3918
US

IV. Provider business mailing address

10390 SPRING VALLEY DR SE
ALTO MI
49302-8400
US

V. Phone/Fax

Practice location:
  • Phone: 616-453-2475
  • Fax:
Mailing address:
  • Phone: 616-307-4015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number5501015081
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: