Provider Demographics
NPI:1346522596
Name:KOENIG, JODI GAYLE (PNP-AC)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:GAYLE
Last Name:KOENIG
Suffix:
Gender:F
Credentials:PNP-AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9223 HUBER RD
Mailing Address - Street 2:
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78155-1973
Mailing Address - Country:US
Mailing Address - Phone:830-379-2663
Mailing Address - Fax:
Practice Address - Street 1:121 DENNIS DR
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-0402
Practice Address - Country:US
Practice Address - Phone:308-372-8981
Practice Address - Fax:830-372-8984
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-14
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP120917363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX339554303Medicaid