Healthcare Provider Details

I. General information

NPI: 1942614268
Provider Name (Legal Business Name): JACLYN KOCH PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2014
Last Update Date: 08/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 E 125TH ST
NEW YORK NY
10035
US

IV. Provider business mailing address

600 E 125TH ST
NEW YORK NY
10035-6000
US

V. Phone/Fax

Practice location:
  • Phone: 646-672-5864
  • Fax:
Mailing address:
  • Phone: 646-672-5864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number019936-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: