Healthcare Provider Details

I. General information

NPI: 1245617356
Provider Name (Legal Business Name): JESSICA COBURN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2015
Last Update Date: 04/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 E WASHINGTON ST
CLARINDA IA
51632-1625
US

IV. Provider business mailing address

215 E WASHINGTON ST
CLARINDA IA
51632-1625
US

V. Phone/Fax

Practice location:
  • Phone: 712-542-3501
  • Fax:
Mailing address:
  • Phone: 712-542-3501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number077247
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: