Provider Demographics
NPI:1891773883
Name:COOK, JASON EVAN (PSYD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:EVAN
Last Name:COOK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1086 FRANKLIN ST
Mailing Address - Street 2:6TH FLOOR
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-4305
Mailing Address - Country:US
Mailing Address - Phone:814-534-1095
Mailing Address - Fax:814-534-1431
Practice Address - Street 1:1020 FRANKLIN ST
Practice Address - Street 2:6TH FLOOR
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-4109
Practice Address - Country:US
Practice Address - Phone:814-534-1085
Practice Address - Fax:814-534-1431
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS008739L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01694292Medicaid
P31108Medicare UPIN
047651Medicare ID - Type Unspecified