Provider Demographics
NPI:1346895976
Name:KOCH, ZACKERY (BA, MAADAC-I)
Entity Type:Individual
Prefix:
First Name:ZACKERY
Middle Name:
Last Name:KOCH
Suffix:
Gender:M
Credentials:BA, MAADAC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-1931
Mailing Address - Country:US
Mailing Address - Phone:417-410-7474
Mailing Address - Fax:
Practice Address - Street 1:302 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-1931
Practice Address - Country:US
Practice Address - Phone:417-410-7474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO11936101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)