Provider Demographics
NPI:1699192211
Name:COOKE, JESSICA (MS ED, BCBA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:COOKE
Suffix:
Gender:F
Credentials:MS ED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 LANSING DR
Mailing Address - Street 2:
Mailing Address - City:MANTUA
Mailing Address - State:NJ
Mailing Address - Zip Code:08051-1200
Mailing Address - Country:US
Mailing Address - Phone:925-594-1704
Mailing Address - Fax:
Practice Address - Street 1:350 LANSING DR
Practice Address - Street 2:
Practice Address - City:MANTUA
Practice Address - State:NJ
Practice Address - Zip Code:08051
Practice Address - Country:US
Practice Address - Phone:925-594-1704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-20
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-14-15295103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
12667951OtherCAQH
14-15-295OtherBACB