Basic Information
| Provider Information | |||||||||
| NPI: | 1164760435 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOKSEY | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | INTERN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2603 E 27TH ST | ||||||||
| Address2: | APT. # A | ||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946011912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103955373 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1931 CENTER ST | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947041105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106669552 | ||||||||
| FaxNumber: | 5106660987 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2013 | ||||||||
| LastUpdateDate: | 01/22/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 000000 | 01 | CA | AC BHCS CLINICIAN # 00 | OTHER |