Provider Demographics
NPI:1619475704
Name:COGNITIVE CARE NETWORK, PLLC
Entity Type:Organization
Organization Name:COGNITIVE CARE NETWORK, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:480-703-5905
Mailing Address - Street 1:3994 E AQUARIUS PL
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85249-5896
Mailing Address - Country:US
Mailing Address - Phone:480-703-5905
Mailing Address - Fax:
Practice Address - Street 1:3994 E AQUARIUS PL
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85249-5896
Practice Address - Country:US
Practice Address - Phone:480-703-5905
Practice Address - Fax:480-703-5905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-24
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1861608861OtherINDIVIDUAL NPI NUMBER