Basic Information
| Provider Information | |||||||||
| NPI: | 1265691257 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COOK BEHAVIORAL HEALTH CLINIC, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | COOK BEHAVIORAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7230 ENGLE RD STE 304 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468042209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604832400 | ||||||||
| FaxNumber: | 2609609361 | ||||||||
| Practice Location | |||||||||
| Address1: | 7230 ENGLE RD STE 304 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468042209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604832400 | ||||||||
| FaxNumber: | 2609609361 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2008 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COOK | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2604832400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PSYD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 20041587A | IN | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 200290630 | 05 | IN | MEDICAID |