Provider Demographics
NPI:1093853111
Name:COOK, JENINE (OTR-L)
Entity Type:Individual
Prefix:MS
First Name:JENINE
Middle Name:
Last Name:COOK
Suffix:
Gender:F
Credentials:OTR-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 W BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-7262
Mailing Address - Country:US
Mailing Address - Phone:602-216-9475
Mailing Address - Fax:
Practice Address - Street 1:1835 E GUADALUPE RD
Practice Address - Street 2:STE 103
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-3277
Practice Address - Country:US
Practice Address - Phone:480-456-0942
Practice Address - Fax:480-456-0956
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0113225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ829294Medicaid