Healthcare Provider Details

I. General information

NPI: 1508270463
Provider Name (Legal Business Name): JESSA MARIE KOCH PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2014
Last Update Date: 03/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 S G ST
SAN BERNARDINO CA
92410-3320
US

IV. Provider business mailing address

250 S G ST
SAN BERNARDINO CA
92410-3320
US

V. Phone/Fax

Practice location:
  • Phone: 855-558-1100
  • Fax:
Mailing address:
  • Phone: 855-558-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP448743
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number75756
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberRP448743
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: