Provider Demographics
NPI:1629399175
Name:COOKE, KENNETH JOHN
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:JOHN
Last Name:COOKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 VIRGINIA BEACH BLVD
Mailing Address - Street 2:440
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-4445
Mailing Address - Country:US
Mailing Address - Phone:757-606-0015
Mailing Address - Fax:
Practice Address - Street 1:3500 VIRGINIA BEACH BLVD
Practice Address - Street 2:440
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-4445
Practice Address - Country:US
Practice Address - Phone:757-606-0015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-18
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701004849101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional