Healthcare Provider Details

I. General information

NPI: 1346261096
Provider Name (Legal Business Name): JIMY ROGER COOK JR. ENP/FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CAMP PENDLETON NAVAL HOSPITAL
CAMP PENDLETON CA
92055-5191
US

IV. Provider business mailing address

33123 TIVOLI ST
TEMECULA CA
92592-4370
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-1184
  • Fax:
Mailing address:
  • Phone: 951-699-9949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number650309
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: