Healthcare Provider Details

I. General information

NPI: 1619191574
Provider Name (Legal Business Name): MARYELLEN KOCH JENSEN DC, MSED, BCBA, LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARYELLEN C. KOCH DC

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 S HALLIBURTON ST
KIRKSVILLE MO
63501-3712
US

IV. Provider business mailing address

430 WAYNE 375
WILLIAMSVILLE MO
63967-8938
US

V. Phone/Fax

Practice location:
  • Phone: 660-341-1105
  • Fax:
Mailing address:
  • Phone: 660-341-1105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number2000148952
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number2018037916
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: