Provider Demographics
NPI:1851263636
Name:COOK, JACOB THEODORE
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:THEODORE
Last Name:COOK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8910 13TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98516-5924
Mailing Address - Country:US
Mailing Address - Phone:360-556-1160
Mailing Address - Fax:
Practice Address - Street 1:8910 13TH AVE NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98516-5924
Practice Address - Country:US
Practice Address - Phone:360-556-1160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-22
Last Update Date:2025-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMHCA.MC.61015940101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty