Healthcare Provider Details

I. General information

NPI: 1225780026
Provider Name (Legal Business Name): JASON JOSEPH KOENIG NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2022
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 E WESTERN RESERVE RD
POLAND OH
44514-3358
US

IV. Provider business mailing address

501 WOODBURY CT
CANFIELD OH
44406-9632
US

V. Phone/Fax

Practice location:
  • Phone: 330-726-3204
  • Fax:
Mailing address:
  • Phone: 330-842-1584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0030593
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: