Provider Demographics
NPI:1457963407
Name:COOK, JODIE MICHELLE
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:MICHELLE
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 1:121 RIG ST
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26847-1641
Mailing Address - Country:US
Mailing Address - Phone:304-257-6740
Mailing Address - Fax:
Practice Address - Street 1:301 BRIGADE DR
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847-9540
Practice Address - Country:US
Practice Address - Phone:304-668-6443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant