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General NPI Number Information
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NPI Number | 1619191574
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Entity Type | Individual
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Provider Name | MARYELLEN KOCH JENSEN DC, MSED, BCBA, LBA
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Gender | Female
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Dates
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Enumeration Date | 04/12/2007
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Last Update Date | 10/21/2024
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Provider Practice Location Address
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Address Line | 606 S HALLIBURTON ST
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City | KIRKSVILLE
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State | MO
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Zip | 63501-3712
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Country | US
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Telephone | 660-341-1105
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Fax |
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Provider Business Mailing Address
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Address Line | 430 WAYNE 375
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City | WILLIAMSVILLE
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State | MO
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Zip | 63967-8938
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Country | US
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Telephone | 660-341-1105
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NN1001X
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Taxonomy Name | Nutrition Chiropractor
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License Number | 2000148952
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 2018037916
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License Number State | MO
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