Provider Demographics
NPI:1437838935
Name:COOK, JONATHAN PATRICK (BTL)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:PATRICK
Last Name:COOK
Suffix:
Gender:M
Credentials:BTL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 VILLAGE SQ STE 210
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21210-1624
Mailing Address - Country:US
Mailing Address - Phone:866-565-7222
Mailing Address - Fax:877-734-1914
Practice Address - Street 1:1314 RIVERLAND RD SE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-3610
Practice Address - Country:US
Practice Address - Phone:866-565-7222
Practice Address - Fax:877-734-1914
Is Sole Proprietor?:No
Enumeration Date:2023-07-13
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-23-257958106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician