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General NPI Number Information
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NPI Number | 1265691257
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Entity Type | Organization
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Legal Business Name | COOK BEHAVIORAL HEALTH CLINIC, PC
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Dates
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Enumeration Date | 06/04/2008
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Last Update Date | 06/11/2019
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Provider Practice Location Address
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Address Line | 7230 ENGLE RD STE 304
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City | FORT WAYNE
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State | IN
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Zip | 46804-2209
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Country | US
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Telephone | 260-483-2400
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Fax | 260-960-9361
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Provider Business Mailing Address
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Address Line | 7230 ENGLE RD STE 304
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City | FORT WAYNE
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State | IN
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Zip | 46804-2209
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Country | US
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Telephone | 260-483-2400
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Fax | 260-960-9361
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Authorized Official
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Title or Position | OWNER
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Name | JASON T COOK
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Credential | PSYD
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Telephone | 260-483-2400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 20041587A
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License Number State | IN
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