Healthcare Provider Details

I. General information

NPI: 1205410594
Provider Name (Legal Business Name): JADEN COOK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2021
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5266 N EAGLE RD
BOISE ID
83713-0945
US

IV. Provider business mailing address

5266 N EAGLE RD
BOISE ID
83713-0945
US

V. Phone/Fax

Practice location:
  • Phone: 208-939-4242
  • Fax:
Mailing address:
  • Phone: 208-939-4242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number12074
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number9481505
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number12074
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: