Healthcare Provider Details

I. General information

NPI: 1609066950
Provider Name (Legal Business Name): JACQUELINE L COOK BC-FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2007
Last Update Date: 06/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 E WALNUT LAWN SUITE 201
SPRINGFIELD MO
65807
US

IV. Provider business mailing address

PO BOX 4046 PO BX 496
SPRINGFIELD MO
65808-4046
US

V. Phone/Fax

Practice location:
  • Phone: 417-269-4450
  • Fax: 417-269-8333
Mailing address:
  • Phone: 417-269-4343
  • Fax: 417-269-7567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number105594
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: