Healthcare Provider Details

I. General information

NPI: 1992395511
Provider Name (Legal Business Name): ANNA C KOCH PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2021
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 S MAIN ST
JONESBORO AR
72401-3503
US

IV. Provider business mailing address

1010 S MAIN ST
JONESBORO AR
72401-3503
US

V. Phone/Fax

Practice location:
  • Phone: 870-932-1820
  • Fax: 870-932-1820
Mailing address:
  • Phone: 870-932-1820
  • Fax: 870-932-1820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3879
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: