Provider Demographics
NPI:1427396928
Name:COCHRAN, JEDIDIAH PATRIOT
Entity Type:Individual
Prefix:MR
First Name:JEDIDIAH
Middle Name:PATRIOT
Last Name:COCHRAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 N LINDA AVE
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74525-1633
Mailing Address - Country:US
Mailing Address - Phone:580-239-2988
Mailing Address - Fax:
Practice Address - Street 1:1410 S GIN RD
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:OK
Practice Address - Zip Code:74525
Practice Address - Country:US
Practice Address - Phone:580-889-3399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-18
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200287120AMedicaid