Provider Demographics
NPI:1730371964
Name:COOK, JENNIFER Q (CNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:Q
Last Name:COOK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 HIGHWAY 51 N
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-2337
Mailing Address - Country:US
Mailing Address - Phone:601-835-2100
Mailing Address - Fax:601-835-0451
Practice Address - Street 1:624 HIGHWAY 51 N
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2337
Practice Address - Country:US
Practice Address - Phone:601-835-2100
Practice Address - Fax:601-835-0451
Is Sole Proprietor?:No
Enumeration Date:2007-08-12
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR865021363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07400054Medicaid
MS371719YS8TMedicare PIN