MEDICARE: KELLY J COOK

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	101YM0800X	Mental Health Counselor		IL

General Provider Information

NPI Number	:	1639003445
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY J COOK

Provider Business Mailing Address
First Line	:	4206 WILLIAMSON PL STE 1
Second Line	:
City	:	MOUNT VERNON
State	:	IL
Zip	:	62864-6761
Country	:	US
Telephone Number	:	618-316-7001
Fax Number	:

Provider Business Practice Location Address
First Line	:	4206 WILLIAMSON PL STE 1
Second Line	:
City	:	MOUNT VERNON
State	:	IL
Zip	:	62864-6761
Country	:	US
Telephone Number	:	618-316-7001
Fax Number	:

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

Provider Enumeration Date	:	06/09/2026
Last Update Date	:	06/09/2026

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Directions to “ KELLY J COOK ” Practice Location

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