=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992661912
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA KOEN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2026
-----------------------------------------------------
Last Update Date | 01/03/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 112 MELVIN RD
-----------------------------------------------------
City | GILBERTOWN
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36908-5254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-843-2292
-----------------------------------------------------
Fax | 800-343-1596
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2578 HORACE ODOM RD
-----------------------------------------------------
City | MILLRY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36558-5069
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 4874G
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------