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General NPI Number Information
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NPI Number | 1891327383
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Entity Type | Individual
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Provider Name | JESSE KOSKOVICK L.P.C.
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Gender | Male
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Dates
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Enumeration Date | 02/12/2020
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Last Update Date | 11/22/2024
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Provider Practice Location Address
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Address Line | 2113 S 54TH ST STE 5
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City | ROGERS
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State | AR
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Zip | 72758-8169
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Country | US
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Telephone | 402-210-8224
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Fax |
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Provider Business Mailing Address
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Address Line | 980 REDFREE DR
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City | BENTONVILLE
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State | AR
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Zip | 72712-3099
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Country | US
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Telephone | 402-210-8224
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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 | 101Y00000X
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Taxonomy Name | Counselor
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License Number | A2107016
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License Number State |
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Taxonomy #2
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number | 19-77966
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License Number State | AR
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Taxonomy #3
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | P2411020
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License Number State | AR
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