Basic Information
| Provider Information | |||||||||
| NPI: | 1194173344 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOK | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | PORTER | ||||||||
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| OtherLastName: | PORTER | ||||||||
| OtherFirstName: | JESSICA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 175 STOCKHAM BLVD APT 2 | ||||||||
| Address2: | |||||||||
| City: | RIGBY | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834421283 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 393 E 2ND N | ||||||||
| Address2: | |||||||||
| City: | REXBURG | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834401605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083599570 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2016 | ||||||||
| LastUpdateDate: | 10/25/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OTL- 1609 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.