Provider Demographics
NPI:1497215982
Name:COOKE, JANETTE SUE
Entity Type:Individual
Prefix:
First Name:JANETTE
Middle Name:SUE
Last Name:COOKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JANETTE
Other - Middle Name:SUE
Other - Last Name:MCMILLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN
Mailing Address - Street 1:5695 S PEPPERVIEW WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-4978
Mailing Address - Country:US
Mailing Address - Phone:949-232-6497
Mailing Address - Fax:
Practice Address - Street 1:90 HOPE DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME AFB
Practice Address - State:ID
Practice Address - Zip Code:83648-1057
Practice Address - Country:US
Practice Address - Phone:208-828-1238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-21
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
CA913470133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty