Provider Demographics
NPI:1235764655
Name:COOK, JACQUELINE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:
Last Name:COOK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9803 W ECHO LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-3723
Mailing Address - Country:US
Mailing Address - Phone:623-628-6893
Mailing Address - Fax:
Practice Address - Street 1:7952 N 43RD AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-1662
Practice Address - Country:US
Practice Address - Phone:623-628-6893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-05
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ239048363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ239048OtherCERTIFIED NURSE PRACTITIONER