Provider Demographics
NPI:1679859458
Name:COOK, JONATHAN
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:COOK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 N ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76901-3363
Mailing Address - Country:US
Mailing Address - Phone:325-659-5413
Mailing Address - Fax:
Practice Address - Street 1:220 N ADAMS ST
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901-3363
Practice Address - Country:US
Practice Address - Phone:325-659-5413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL 062805-5164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse