Provider Demographics
NPI:1164760435
Name:COOKSEY, JESSE R (INTERN)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:R
Last Name:COOKSEY
Suffix:
Gender:M
Credentials:INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2603 E 27TH ST
Mailing Address - Street 2:APT. # A
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-1912
Mailing Address - Country:US
Mailing Address - Phone:510-395-5373
Mailing Address - Fax:
Practice Address - Street 1:1931 CENTER ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-1105
Practice Address - Country:US
Practice Address - Phone:510-666-9552
Practice Address - Fax:510-666-0987
Is Sole Proprietor?:No
Enumeration Date:2013-01-22
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000000OtherAC BHCS CLINICIAN # 00