Healthcare Provider Details

I. General information

NPI: 1033284229
Provider Name (Legal Business Name): JERRY ALAN COOKE LISW LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 03/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1482B S ST FRANCIS DR
SANTA FE NM
87505-4098
US

IV. Provider business mailing address

1482B S ST FRANCIS DR
SANTA FE NM
87505-4098
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-3676
  • Fax:
Mailing address:
  • Phone: 505-983-3676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number348
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI0879
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: