Provider Demographics
NPI:1083025613
Name:KOCH, JEAN THERESA (DC)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:THERESA
Last Name:KOCH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 PLANK RD STE 1022
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-0120
Mailing Address - Country:US
Mailing Address - Phone:540-785-0200
Mailing Address - Fax:
Practice Address - Street 1:4500 PLANK RD STE 1022
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-0120
Practice Address - Country:US
Practice Address - Phone:540-785-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-16
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104-557170111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor