Healthcare Provider Details

I. General information

NPI: 1902120306
Provider Name (Legal Business Name): JEAN MARIE KOCH-FOGEL MSW, CAP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2010
Last Update Date: 03/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4422 E. COLUMBUS DRIVE
TAMPA FL
33605
US

IV. Provider business mailing address

4422 E. COLUMBUS DRIVE
TAMPA FL
33605
US

V. Phone/Fax

Practice location:
  • Phone: 813-384-4000
  • Fax:
Mailing address:
  • Phone: 813-384-4000
  • Fax: 813-630-0082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4397C.AP.
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: