Healthcare Provider Details

I. General information

NPI: 1538322284
Provider Name (Legal Business Name): NANCY JANE COOK LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11921 MASON RD
LICKING MO
65542-9066
US

IV. Provider business mailing address

11921 MASON RD PO BOX 594
LICKING MO
65542-9066
US

V. Phone/Fax

Practice location:
  • Phone: 417-217-1078
  • Fax: 573-674-4064
Mailing address:
  • Phone: 417-217-1078
  • Fax: 573-674-4064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2006034293
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: