Provider Demographics
NPI:1376262089
Name:COOK, JACQUELINE GALE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:GALE
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 1:105 ERVIN CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-9148
Mailing Address - Country:US
Mailing Address - Phone:704-534-1214
Mailing Address - Fax:
Practice Address - Street 1:105 ERVIN CT
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-9148
Practice Address - Country:US
Practice Address - Phone:704-534-1214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC31632183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist