Provider Demographics
NPI:1437345279
Name:COOK, JEFFREY CHAD (IDC)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:CHAD
Last Name:COOK
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MCM CREW IMPERVIOUS
Mailing Address - Street 2:MEDICAL DEPARTMENT
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09501 1901
Mailing Address - Country:US
Mailing Address - Phone:361-438-1994
Mailing Address - Fax:
Practice Address - Street 1:MCM CREW IMPERVIOUS
Practice Address - Street 2:MEDICAL DEPARTMENT
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09501 1901
Practice Address - Country:US
Practice Address - Phone:361-438-1994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-14
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
No1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians