Provider Demographics
NPI:1043381692
Name:KOENEN, JACK (DC)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:KOENEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 S CLARK ST
Mailing Address - Street 2:
Mailing Address - City:FOREST CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50436-1810
Mailing Address - Country:US
Mailing Address - Phone:641-582-4625
Mailing Address - Fax:641-582-5510
Practice Address - Street 1:209 S CLARK ST
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:IA
Practice Address - Zip Code:50436-1810
Practice Address - Country:US
Practice Address - Phone:641-582-4625
Practice Address - Fax:641-582-5510
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA04849111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA6503OtherMIDLANDS CHOICE
IA20085OtherWELLMARK
IA0200857Medicaid
IA0200857Medicaid
IA20085Medicare ID - Type Unspecified