Healthcare Provider Details

I. General information

NPI: 1770726945
Provider Name (Legal Business Name): JENNIFER KOCH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2009
Last Update Date: 06/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2014 WASHINGTON ST NEWTON-WELLESLEY HOSPITAL
NEWTON MA
02462-1607
US

IV. Provider business mailing address

2014 WASHINGTON ST NEWTON-WELLESLEY HOSPITAL
NEWTON MA
02462-1607
US

V. Phone/Fax

Practice location:
  • Phone: 617-243-6490
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number250544
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number250544
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: