Provider Demographics
NPI:1033284229
Name:COOKE, JERRY ALAN (LISW LADC)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:ALAN
Last Name:COOKE
Suffix:
Gender:M
Credentials:LISW LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1482B S ST FRANCIS DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4098
Mailing Address - Country:US
Mailing Address - Phone:505-983-3676
Mailing Address - Fax:
Practice Address - Street 1:1482B S ST FRANCIS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4098
Practice Address - Country:US
Practice Address - Phone:505-983-3676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK348101YA0400X
NMI0879104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMQ6658Medicaid