Healthcare Provider Details

I. General information

NPI: 1700991494
Provider Name (Legal Business Name): JACCI RAE KOERNER TLMLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 E GRANT AVE
GREENSBURG KS
67054-2708
US

IV. Provider business mailing address

207 W WISCONSIN AVE
GREENSBURG KS
67054-1750
US

V. Phone/Fax

Practice location:
  • Phone: 620-723-2272
  • Fax: 620-723-3450
Mailing address:
  • Phone: 620-723-2214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberTLMLP 1020
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: