Provider Demographics
NPI:1417905191
Name:KOEHRSEN, JACK BRIAN (MA, LPC, LPCC)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:BRIAN
Last Name:KOEHRSEN
Suffix:
Gender:M
Credentials:MA, LPC, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 COLLIERS WAY
Mailing Address - Street 2:SUITE C
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-5012
Mailing Address - Country:US
Mailing Address - Phone:304-723-4260
Mailing Address - Fax:304-723-4264
Practice Address - Street 1:485 COLLIERS WAY
Practice Address - Street 2:SUITE C
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-5012
Practice Address - Country:US
Practice Address - Phone:304-723-4260
Practice Address - Fax:304-723-4264
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1056101Y00000X
OHE0001217101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV337925OtherVALUE OPTIONS
OHHEALTH PLANOtherY141250A
OHANTHEMOther000000218506
WVAETNAOther5014701