=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023498359
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN COOK
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2015
-----------------------------------------------------
Last Update Date | 06/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1699 RED WOLF BLVD SUITE I
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72401-5442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-336-0543
-----------------------------------------------------
Fax | 870-336-0061
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1601 CASTLE DR
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72401-5100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-530-4234
-----------------------------------------------------
Fax | 870-336-0061
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 4038
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------