Provider Demographics
NPI:1255848545
Name:COOK, ALISIA DEANN
Entity Type:Individual
Prefix:
First Name:ALISIA
Middle Name:DEANN
Last Name:COOK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:781 BLACK OAK DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-9502
Mailing Address - Country:US
Mailing Address - Phone:541-789-4712
Mailing Address - Fax:541-789-4060
Practice Address - Street 1:781 BLACK OAK DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-9502
Practice Address - Country:US
Practice Address - Phone:541-789-4712
Practice Address - Fax:541-789-4060
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator