Healthcare Provider Details

I. General information

NPI: 1619251816
Provider Name (Legal Business Name): JENNA MARIE COOKE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2011
Last Update Date: 06/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 HAYNES STREET
MANCHESTER CT
06040-4188
US

IV. Provider business mailing address

101 N PLAINS INDUSTRIAL RD
WALLINGFORD CT
06492-2360
US

V. Phone/Fax

Practice location:
  • Phone: 860-871-6710
  • Fax: 860-896-4869
Mailing address:
  • Phone: 203-949-2700
  • Fax: 203-949-2712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number004738
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: