Provider Demographics
NPI:1356811046
Name:COOK, JENNIFER JANE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JANE
Last Name:COOK
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 1:701 MADISON DR
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE GROVE
Mailing Address - State:AR
Mailing Address - Zip Code:72753-2871
Mailing Address - Country:US
Mailing Address - Phone:479-715-3875
Mailing Address - Fax:870-741-4066
Practice Address - Street 1:2153 E JOYCE BLVD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4714
Practice Address - Country:US
Practice Address - Phone:479-575-9471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health