Basic Information
| Provider Information | |||||||||
| NPI: | 1043283641 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOK | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | T. | ||||||||
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| Credential: | PSY.D., HSPP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7230 ENGLE RD | ||||||||
| Address2: | STE 304 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468042209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604812700 | ||||||||
| FaxNumber: | 2604812717 | ||||||||
| Practice Location | |||||||||
| Address1: | 7230 ENGLE RD | ||||||||
| Address2: | STE 304 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468042209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604832400 | ||||||||
| FaxNumber: | 2609609361 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 10/02/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 20041587A | IN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 200290630 | 05 | IN | MEDICAID |