Provider Demographics
NPI:1497030068
Name:COOKSEY, JACK (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:COOKSEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 LAWNDALE AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1157
Mailing Address - Country:US
Mailing Address - Phone:847-475-8184
Mailing Address - Fax:
Practice Address - Street 1:2505 LAWNDALE AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1157
Practice Address - Country:US
Practice Address - Phone:847-475-8184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-14
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036038562174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD14543Medicare UPIN
IL664100Medicare PIN