Provider Demographics
NPI:1205675402
Name:COOK, JALEN THOMAS
Entity type:Individual
Prefix:
First Name:JALEN
Middle Name:THOMAS
Last Name:COOK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3185 W STATE ST STE 2010
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-1600
Mailing Address - Country:US
Mailing Address - Phone:423-968-7555
Mailing Address - Fax:
Practice Address - Street 1:3185 W STATE ST STE 2010
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-1600
Practice Address - Country:US
Practice Address - Phone:423-968-7555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN123456789152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist