Provider Demographics
NPI:1568587194
Name:COOK, JEREMIAH W (LMT)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:W
Last Name:COOK
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 610
Mailing Address - Street 2:
Mailing Address - City:CARLTON
Mailing Address - State:OR
Mailing Address - Zip Code:97111-0610
Mailing Address - Country:US
Mailing Address - Phone:503-939-2946
Mailing Address - Fax:
Practice Address - Street 1:310 S 3RD ST
Practice Address - Street 2:
Practice Address - City:CARLTON
Practice Address - State:OR
Practice Address - Zip Code:97111-0610
Practice Address - Country:US
Practice Address - Phone:503-939-2946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13614225700000X
WAMA00023290225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist