Provider Demographics
NPI:1790259729
Name:COOKS, JUANITA R
Entity Type:Individual
Prefix:MRS
First Name:JUANITA
Middle Name:R
Last Name:COOKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3224 LIBERTY CIR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32206-2101
Mailing Address - Country:US
Mailing Address - Phone:904-337-0657
Mailing Address - Fax:904-337-0657
Practice Address - Street 1:3224 LIBERTY CIR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206-2101
Practice Address - Country:US
Practice Address - Phone:904-337-0657
Practice Address - Fax:904-337-0657
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-12
Last Update Date:2019-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3747P1801X3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL230644100Medicaid