=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366490203
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEAN COOK LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2006
-----------------------------------------------------
Last Update Date | 03/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 CROSSING LN STE 101
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24450-6354
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-461-1824
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 22
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24450-0022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-461-1824
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 0904003408
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------