Provider Demographics
NPI:1205083532
Name:JENNIFER COOKE STAAT, P.A.
Entity type:Organization
Organization Name:JENNIFER COOKE STAAT, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:COOKE
Authorized Official - Last Name:STAAT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:910-547-3093
Mailing Address - Street 1:4608 CEDAR AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-4419
Mailing Address - Country:US
Mailing Address - Phone:910-547-3093
Mailing Address - Fax:
Practice Address - Street 1:4608 CEDAR AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-4419
Practice Address - Country:US
Practice Address - Phone:910-547-3093
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2505103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty