Healthcare Provider Details

I. General information

NPI: 1831822980
Provider Name (Legal Business Name): JESSICA ELIZABETH COOK FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2022
Last Update Date: 07/06/2022
Certification Date: 06/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 HARPER DR NE
ALBUQUERQUE NM
87109-3587
US

IV. Provider business mailing address

PO BOX 26666
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-823-8888
  • Fax:
Mailing address:
  • Phone: 505-823-8927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number68846
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: