MEDICARE: JASON EVAN COOK PSYD

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	103T00000X	Psychologist	PS008739L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891773883
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASON EVAN COOK PSYD

Provider Business Mailing Address
First Line	:	1086 FRANKLIN ST
Second Line	:	6TH FLOOR
City	:	JOHNSTOWN
State	:	PA
Zip	:	15905-4305
Country	:	US
Telephone Number	:	814-534-1095
Fax Number	:	814-534-1431

Provider Business Practice Location Address
First Line	:	1020 FRANKLIN ST
Second Line	:	6TH FLOOR
City	:	JOHNSTOWN
State	:	PA
Zip	:	15905-4109
Country	:	US
Telephone Number	:	814-534-1085
Fax Number	:	814-534-1431

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

Provider Enumeration Date	:	01/09/2006
Last Update Date	:	07/08/2007

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