Provider Demographics
NPI:1902883119
Name:STAAT, JENNIFER COOKE (PHD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:COOKE
Last Name:STAAT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LEE
Other - Last Name:COOKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:4608 CEDAR AVENUE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403
Mailing Address - Country:US
Mailing Address - Phone:910-547-3093
Mailing Address - Fax:
Practice Address - Street 1:4608 CEDAR AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-4419
Practice Address - Country:US
Practice Address - Phone:910-547-3093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2505103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC240133OtherCOMPSYCH
NYNCMC034119OtherVALUE OPTIONS
NC046K0OtherBLUE CROSS BLUE SHIELD
NCD6590OtherMEDCOST
NC6000577Medicaid
NC6000577Medicaid