Basic Information
| Provider Information | |||||||||
| NPI: | 1740610203 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOKE | ||||||||
| FirstName: | JENNY | ||||||||
| MiddleName: | VUONG | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VUONG | ||||||||
| OtherFirstName: | JENNY | ||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5603 RAMSEY ST | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283111423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104886337 | ||||||||
| FaxNumber: | 9104881384 | ||||||||
| Practice Location | |||||||||
| Address1: | 2401 MONUMENT RD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322252520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046420337 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2013 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9109392 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 001004534 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.