MEDICARE: MR. JACK COONEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	070702863	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	070708623	OTHER	CA	NATABBOC

General Provider Information

NPI Number	:	1538821350
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JACK COONEY

Provider Business Mailing Address
First Line	:	114 CLARENDON AVE
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94114-2104
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	930 COLE ST STE 103
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94117-4367
Country	:	US
Telephone Number	:	415-841-2721
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/08/2021
Last Update Date	:	10/08/2021

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Directions to “ MR. JACK COONEY ” Practice Location

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