Provider Demographics
NPI:1427699479
Name:COOK, JACLYN
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:COOK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 JODY RAE ST
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-7707
Mailing Address - Country:US
Mailing Address - Phone:269-357-9183
Mailing Address - Fax:
Practice Address - Street 1:2424 JODY RAE ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-7707
Practice Address - Country:US
Practice Address - Phone:269-357-9183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist