Healthcare Provider Details

I. General information

NPI: 1255921516
Provider Name (Legal Business Name): JESSICA LYNN KOCH DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2021
Last Update Date: 01/21/2021
Certification Date: 01/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 MAIN ST
GILBOA OH
45875-9757
US

IV. Provider business mailing address

235 TANGLEWOOD DR
OTTAWA OH
45875-1064
US

V. Phone/Fax

Practice location:
  • Phone: 567-376-9150
  • Fax:
Mailing address:
  • Phone: 419-615-3022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT014186
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: