Healthcare Provider Details

I. General information

NPI: 1417905191
Provider Name (Legal Business Name): JACK BRIAN KOEHRSEN MA, LPC, LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

485 COLLIERS WAY SUITE C
WEIRTON WV
26062-5012
US

IV. Provider business mailing address

485 COLLIERS WAY SUITE C
WEIRTON WV
26062-5012
US

V. Phone/Fax

Practice location:
  • Phone: 304-723-4260
  • Fax: 304-723-4264
Mailing address:
  • Phone: 304-723-4260
  • Fax: 304-723-4264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number1056
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberE0001217
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: