Healthcare Provider Details

I. General information

NPI: 1700319928
Provider Name (Legal Business Name): JOHN COOK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2017
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 N 5TH ST
LEESVILLE LA
71446
US

IV. Provider business mailing address

2525 YOUREE DR SUITE 110
SHREVEPORT LA
71104-3671
US

V. Phone/Fax

Practice location:
  • Phone: 337-238-4350
  • Fax: 337-238-4352
Mailing address:
  • Phone: 318-675-0804
  • Fax: 318-425-9030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: