Provider Demographics
NPI:1518941517
Name:WILSON, JACK COOK (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:COOK
Last Name:WILSON
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 1:924 CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-2053
Mailing Address - Country:US
Mailing Address - Phone:870-424-3652
Mailing Address - Fax:
Practice Address - Street 1:612 E 9TH ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-4804
Practice Address - Country:US
Practice Address - Phone:870-424-3652
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC3223207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR55740OtherBLUE CROSS BLUE SHIELD ID
AR16022000000OtherQUALCHOICE PROVIDER ID #
AR16022000000OtherQUALCHOICE PROVIDER ID #
AR55740Medicare ID - Type UnspecifiedMEDICARE