Provider Demographics
NPI:1629259361
Name:COOK, JACEY LYNN (LLP)
Entity Type:Individual
Prefix:MRS
First Name:JACEY
Middle Name:LYNN
Last Name:COOK
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 E 7TH AVE
Mailing Address - Street 2:SUITE 9
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-3111
Mailing Address - Country:US
Mailing Address - Phone:906-635-7270
Mailing Address - Fax:906-635-7688
Practice Address - Street 1:605 E 7TH AVE
Practice Address - Street 2:SUITE 9
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-3111
Practice Address - Country:US
Practice Address - Phone:906-635-7270
Practice Address - Fax:906-635-7688
Is Sole Proprietor?:No
Enumeration Date:2007-11-23
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013688103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical