Healthcare Provider Details

I. General information

NPI: 1730135567
Provider Name (Legal Business Name): JON ROSS COOK PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 EVERETT LN
CLARKDALE AZ
86324-3726
US

IV. Provider business mailing address

551 EVERETT LN
CLARKDALE AZ
86324-3726
US

V. Phone/Fax

Practice location:
  • Phone: 928-202-7187
  • Fax:
Mailing address:
  • Phone: 928-202-7187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number6462
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: