Healthcare Provider Details

I. General information

NPI: 1912088899
Provider Name (Legal Business Name): JENNIFER KOCH CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER M WALDEN

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 WEST AVE S
LA CROSSE WI
54601-4783
US

IV. Provider business mailing address

PO BOX 1510
EAU CLAIRE WI
54702-1510
US

V. Phone/Fax

Practice location:
  • Phone: 608-785-0940
  • Fax: 608-392-9898
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number152935
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number152935
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: