Basic Information
| Provider Information | |||||||||
| NPI: | 1194914473 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COOK | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | MS, CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 144 QUAIL RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376016313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2766134694 | ||||||||
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| Practice Location | |||||||||
| Address1: | 185 CHARLOIS BLVD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271031521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367250222 | ||||||||
| FaxNumber: | 3367250454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2007 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 7356 | NC | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 5208 | TN | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.