Healthcare Provider Details

I. General information

NPI: 1609450352
Provider Name (Legal Business Name): JENNA KOCH M.S., LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2021
Last Update Date: 05/10/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20700 WATERTOWN RD STE 102
WAUKESHA WI
53186-1800
US

IV. Provider business mailing address

20700 WATERTOWN RD STE 102
WAUKESHA WI
53186-1800
US

V. Phone/Fax

Practice location:
  • Phone: 262-782-1474
  • Fax: 262-782-1441
Mailing address:
  • Phone: 262-782-1474
  • Fax: 262-782-1441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number8191-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: