Provider Demographics
NPI:1407887227
Name:COOL, JAY MARK (PA)
Entity Type:Individual
Prefix:MR
First Name:JAY
Middle Name:MARK
Last Name:COOL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 E MAIN ST
Mailing Address - Street 2:APT 6110
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-4077
Mailing Address - Country:US
Mailing Address - Phone:814-266-8696
Mailing Address - Fax:
Practice Address - Street 1:31115 HIGHWAY 94
Practice Address - Street 2:
Practice Address - City:CAMPO
Practice Address - State:CA
Practice Address - Zip Code:91906
Practice Address - Country:US
Practice Address - Phone:619-445-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA001083L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical