Healthcare Provider Details

I. General information

NPI: 1114923737
Provider Name (Legal Business Name): JACK L. KOCH JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1507 16TH AVE S
NASHVILLE TN
37212-2905
US

IV. Provider business mailing address

1507 16TH AVE S
NASHVILLE TN
37212-2905
US

V. Phone/Fax

Practice location:
  • Phone: 615-515-7775
  • Fax: 615-523-1483
Mailing address:
  • Phone: 615-515-7775
  • Fax: 615-523-1483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number27427
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number27427
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: