Provider Demographics
NPI:1346261096
Name:COOK, JIMY ROGER JR (ENP/FNP)
Entity Type:Individual
Prefix:
First Name:JIMY
Middle Name:ROGER
Last Name:COOK
Suffix:JR
Gender:M
Credentials:ENP/FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33123 TIVOLI ST
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-4370
Mailing Address - Country:US
Mailing Address - Phone:951-699-9949
Mailing Address - Fax:
Practice Address - Street 1:CAMP PENDLETON NAVAL HOSPITAL
Practice Address - Street 2:
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055-5191
Practice Address - Country:US
Practice Address - Phone:760-725-1184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX650309363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner