Healthcare Provider Details

I. General information

NPI: 1891327383
Provider Name (Legal Business Name): JESSE KOSKOVICK L.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2020
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2113 S 54TH ST STE 5
ROGERS AR
72758-8169
US

IV. Provider business mailing address

980 REDFREE DR
BENTONVILLE AR
72712-3099
US

V. Phone/Fax

Practice location:
  • Phone: 402-210-8224
  • Fax:
Mailing address:
  • Phone: 479-357-2661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number19-77966
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP2411020
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberA2107016
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: