MEDICARE: MS. JAQUIERRA COOK RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WC0200X	Critical Care Medicine Registered Nurse	674611	NY

General Provider Information

NPI Number	:	1356012967
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JAQUIERRA COOK RN

Provider Business Mailing Address
First Line	:	2345 LINWOOD AVE APT LH
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024-3844
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2345 LINWOOD AVE APT LH
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024-3844
Country	:	US
Telephone Number	:	845-537-0165
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/23/2021
Last Update Date	:	09/23/2021

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