Provider Demographics
NPI:1265001044
Name:COOKE, LAURA JANE
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:JANE
Last Name:COOKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:J
Other - Last Name:COOKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BCBA
Mailing Address - Street 1:4051 ANTLER DR
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72936-6804
Mailing Address - Country:US
Mailing Address - Phone:479-651-4805
Mailing Address - Fax:
Practice Address - Street 1:4051 ANTLER DR
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:AR
Practice Address - Zip Code:72936-6804
Practice Address - Country:US
Practice Address - Phone:479-651-4805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-24
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR201686706Medicaid