Healthcare Provider Details

I. General information

NPI: 1225803893
Provider Name (Legal Business Name): JARED ADAM KOCH RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2023
Last Update Date: 11/23/2023
Certification Date: 11/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7165 CLEARVISTA WAY
INDIANAPOLIS IN
46256-4621
US

IV. Provider business mailing address

601 WALLACE AVE
INDIANAPOLIS IN
46201-2927
US

V. Phone/Fax

Practice location:
  • Phone: 317-621-5000
  • Fax:
Mailing address:
  • Phone: 317-532-7389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number28255887A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: