Basic Information
| Provider Information | |||||||||
| NPI: | 1023203379 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COOK | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | JACK | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15095 AMARGOSA RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923941879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607804016 | ||||||||
| FaxNumber: | 7607804005 | ||||||||
| Practice Location | |||||||||
| Address1: | 15095 AMARGOSA RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923941879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602454695 | ||||||||
| FaxNumber: | 7602455896 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2007 | ||||||||
| LastUpdateDate: | 12/09/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.