Provider Demographics
NPI:1881930774
Name:COOK, JEFFREY DOUGLAS (PHD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DOUGLAS
Last Name:COOK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 W MAIN ST STE G
Mailing Address - Street 2:
Mailing Address - City:WHITEWATER
Mailing Address - State:WI
Mailing Address - Zip Code:53190-1995
Mailing Address - Country:US
Mailing Address - Phone:262-379-0419
Mailing Address - Fax:
Practice Address - Street 1:162 W MAIN ST STE G
Practice Address - Street 2:
Practice Address - City:WHITEWATER
Practice Address - State:WI
Practice Address - Zip Code:53190-1995
Practice Address - Country:US
Practice Address - Phone:262-379-0419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-20
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4946-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional