Healthcare Provider Details

I. General information

NPI: 1184699324
Provider Name (Legal Business Name): MR. BRADLEY JASON COOK
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1689 NONCONNAH BLVD SUITE 105
MEMPHIS TN
38132-2102
US

IV. Provider business mailing address

1153 GREENVIEW RD
COLLIERVILLE TN
38017-6884
US

V. Phone/Fax

Practice location:
  • Phone: 901-797-6805
  • Fax:
Mailing address:
  • Phone: 901-850-7750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0000000833
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: