Provider Demographics
NPI:1962023853
Name:COOK, JENNIFER (LD, LMSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:COOK
Suffix:
Gender:F
Credentials:LD, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 N STATE HIGHWAY 360 STE 350
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-1451
Mailing Address - Country:US
Mailing Address - Phone:817-812-4723
Mailing Address - Fax:817-812-6042
Practice Address - Street 1:2080 N STATE HIGHWAY 360 STE 350
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-1451
Practice Address - Country:US
Practice Address - Phone:817-812-4723
Practice Address - Fax:817-812-6042
Is Sole Proprietor?:No
Enumeration Date:2020-05-01
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT84249133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDT84249OtherLD LICENSE