Provider Demographics
NPI:1881719490
Name:COCKAYNE, JEFFREY BENNION (LCPC)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:BENNION
Last Name:COCKAYNE
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:JEFF
Other - Middle Name:
Other - Last Name:COCKAYNE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCPC
Mailing Address - Street 1:2200 S AMMON RD # 1
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-6852
Mailing Address - Country:US
Mailing Address - Phone:208-522-4795
Mailing Address - Fax:
Practice Address - Street 1:496 A ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3617
Practice Address - Country:US
Practice Address - Phone:208-552-7100
Practice Address - Fax:208-552-7101
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC - 3730101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID80611000Medicaid
ID1378585Medicare ID - Type UnspecifiedCLINIC