Basic Information
| Provider Information | |||||||||
| NPI: | 1699953158 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOK | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | ALLAN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1363 W SPRUCE AVE | ||||||||
| Address2: | |||||||||
| City: | WASILLA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073762411 | ||||||||
| FaxNumber: | 9073523363 | ||||||||
| Practice Location | |||||||||
| Address1: | 1363 W SPRUCE AVE | ||||||||
| Address2: | |||||||||
| City: | WASILLA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073762411 | ||||||||
| FaxNumber: | 9073523363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2008 | ||||||||
| LastUpdateDate: | 03/15/2017 | ||||||||
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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 | 101YM0800X | C005914 | NC | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | CSWS381 | AK | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 561949434 | 01 | NC | BCBS | OTHER |