Provider Demographics
NPI:1780058578
Name:JAN HAGWOOD COCKE, M.A., CCC-SLP, LLC
Entity type:Organization
Organization Name:JAN HAGWOOD COCKE, M.A., CCC-SLP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:HAGWOOD
Authorized Official - Last Name:COCKE
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC-SLP
Authorized Official - Phone:8033-748-7459
Mailing Address - Street 1:3221 PLUM CIR
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-3148
Mailing Address - Country:US
Mailing Address - Phone:803-378-7459
Mailing Address - Fax:803-536-4922
Practice Address - Street 1:3221 PLUM CIR
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-3148
Practice Address - Country:US
Practice Address - Phone:803-378-7459
Practice Address - Fax:803-536-4922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3546235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0548Medicaid