Healthcare Provider Details

I. General information

NPI: 1346690252
Provider Name (Legal Business Name): JACQUELINE KOSHOREK D.O
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15255 N 40TH ST SUITE 127/129, ROOM 1
PHOENIX AZ
85032
US

IV. Provider business mailing address

3370 N HAYDEN RD SUITE 123 PMB 283
SCOTTSDALE AZ
85251
US

V. Phone/Fax

Practice location:
  • Phone: 602-759-9438
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number009660
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: