Provider Demographics
NPI:1427243542
Name:COOK, JENNIFER LIANE (LPCC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LIANE
Last Name:COOK
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LIANE
Other - Last Name:MALLICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:2320 RIO GRANDE BLVD. SE
Mailing Address - Street 2:SUITE D
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124
Mailing Address - Country:US
Mailing Address - Phone:505-219-1125
Mailing Address - Fax:
Practice Address - Street 1:2320 RIO GRANDE BLVD. SE
Practice Address - Street 2:SUITE D
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124
Practice Address - Country:US
Practice Address - Phone:505-219-1125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCCMH0180961101YM0800X
101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM59652314Medicaid