Healthcare Provider Details

I. General information

NPI: 1528207784
Provider Name (Legal Business Name): JENNIFER ELIZABETH KOCH PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2009
Last Update Date: 06/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2502 E EMPIRE ST STE C
BLOOMINGTON IL
61704-3739
US

IV. Provider business mailing address

PO BOX 604
BLOOMINGTON IL
61702-0604
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-7220
  • Fax:
Mailing address:
  • Phone: 309-663-7220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.007625
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: