Provider Demographics
NPI:1346584885
Name:COOKE, JACOB TANNER (MS, CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:TANNER
Last Name:COOKE
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 KIMBERLY DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-9604
Mailing Address - Country:US
Mailing Address - Phone:336-648-0007
Mailing Address - Fax:
Practice Address - Street 1:140 KIMBERLY DR
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-9604
Practice Address - Country:US
Practice Address - Phone:336-648-0007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-21
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9885235Z00000X
NC14061396235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist