Healthcare Provider Details

I. General information

NPI: 1356811046
Provider Name (Legal Business Name): JENNIFER JANE COOK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2018
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2153 E JOYCE BLVD
FAYETTEVILLE AR
72703-4714
US

IV. Provider business mailing address

701 MADISON DR
PRAIRIE GROVE AR
72753-2871
US

V. Phone/Fax

Practice location:
  • Phone: 479-575-9471
  • Fax:
Mailing address:
  • Phone: 479-715-3875
  • Fax: 870-741-4066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: