Provider Demographics
NPI:1972690303
Name:COCKBURN, JACK TAYLOR (PHD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:TAYLOR
Last Name:COCKBURN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 DEGAN
Mailing Address - Street 2:#103
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057
Mailing Address - Country:US
Mailing Address - Phone:972-436-8881
Mailing Address - Fax:972-355-7934
Practice Address - Street 1:131 DEGAN
Practice Address - Street 2:#103
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057
Practice Address - Country:US
Practice Address - Phone:972-436-8881
Practice Address - Fax:972-355-7934
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14096101YP2500X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX028530601Medicaid