Provider Demographics
NPI:1043283641
Name:COOK, JASON T (PSYD, HSPP)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:T
Last Name:COOK
Suffix:
Gender:M
Credentials:PSYD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7230 ENGLE RD
Mailing Address - Street 2:STE 304
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-2209
Mailing Address - Country:US
Mailing Address - Phone:260-481-2700
Mailing Address - Fax:260-481-2717
Practice Address - Street 1:7230 ENGLE RD
Practice Address - Street 2:STE 304
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-2209
Practice Address - Country:US
Practice Address - Phone:260-483-2400
Practice Address - Fax:260-960-9361
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041587A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200290630Medicaid
IN200290630Medicaid