=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205843034
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEANNE WYNN COOK MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2006
-----------------------------------------------------
Last Update Date | 06/30/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2324 E CESAR CHAVEZ ST
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78702-4604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-387-5813
-----------------------------------------------------
Fax | 512-277-6016
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1815 ALTA VISTA AVE
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78704-3152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-387-5813
-----------------------------------------------------
Fax | 512-277-6016
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | H2315
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------