Healthcare Provider Details

I. General information

NPI: 1205165784
Provider Name (Legal Business Name): JACOB JOHN KOCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2009
Last Update Date: 12/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4020 FOLKER ST ALASKA COMMUNITY MENTAL HEALTH SERVICE
ANCHORAGE AK
97508
US

IV. Provider business mailing address

324 FOGGY CUT LN
LANDRUM SC
29356-3145
US

V. Phone/Fax

Practice location:
  • Phone: 864-895-5599
  • Fax:
Mailing address:
  • Phone: 864-895-5599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301023325
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: