MEDICARE: JOHN T COOKE LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	LPC003958	GA

General Provider Information

NPI Number	:	1134346331
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN T COOKE LPC

Provider Business Mailing Address
First Line	:	1457 ESTER CT
Second Line	:
City	:	RIVERDALE
State	:	GA
Zip	:	30296-2154
Country	:	US
Telephone Number	:	770-991-1653
Fax Number	:

Provider Business Practice Location Address
First Line	:	139 HENRY PKWY
Second Line	:
City	:	MCDONOUGH
State	:	GA
Zip	:	30253-6636
Country	:	US
Telephone Number	:	770-898-7400
Fax Number	:	770-898-7412

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/19/2007
Last Update Date	:	07/08/2007

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