MEDICARE: JENNY V COUCH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	LPC-12004	AZ
2	101YP2500X	Professional Counselor	60569

General Provider Information

NPI Number	:	1790105062
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNY V COUCH

Provider Business Mailing Address
First Line	:	24906 W BOONE DR
Second Line	:
City	:	CASA GRANDE
State	:	AZ
Zip	:	85193-8268
Country	:	US
Telephone Number	:	520-405-7575
Fax Number	:

Provider Business Practice Location Address
First Line	:	24906 W BOONE DR
Second Line	:
City	:	CASA GRANDE
State	:	AZ
Zip	:	85193-8268
Country	:	US
Telephone Number	:	520-405-7575
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/24/2014
Last Update Date	:	04/24/2014

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