Provider Demographics
NPI:1730135567
Name:COOK, JON ROSS (PT)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:ROSS
Last Name:COOK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4542 E BUTTE DR
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-5965
Mailing Address - Country:US
Mailing Address - Phone:928-649-0990
Mailing Address - Fax:
Practice Address - Street 1:657 E COTTONWOOD ST
Practice Address - Street 2:SUITE 10B
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4407
Practice Address - Country:US
Practice Address - Phone:928-646-7051
Practice Address - Fax:928-646-7053
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6462174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist