Healthcare Provider Details

I. General information

NPI: 1699110460
Provider Name (Legal Business Name): JEANIE T KOCH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2013
Last Update Date: 05/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 IRONSTONE CT
ROSEVILLE CA
95747-5840
US

IV. Provider business mailing address

200 IRONSTONE CT
ROSEVILLE CA
95747-5840
US

V. Phone/Fax

Practice location:
  • Phone: 916-743-6126
  • Fax:
Mailing address:
  • Phone: 916-743-6126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number712669
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: