Healthcare Provider Details

I. General information

NPI: 1194720052
Provider Name (Legal Business Name): JACK T. COOK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 06/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 PLEASANT STREET YEAPLE BUILDING
CONCORD NH
03301-7539
US

IV. Provider business mailing address

250 PLEASANT STREET YEAPLE BUILDING
CONCORD NH
03301-7539
US

V. Phone/Fax

Practice location:
  • Phone: 603-228-7200
  • Fax: 603-228-7307
Mailing address:
  • Phone: 603-228-7200
  • Fax: 603-228-7307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number432
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: