Provider Demographics
NPI:1619191574
Name:JENSEN, MARYELLEN KOCH (DC, MSED, BCBA, LBA)
Entity Type:Individual
Prefix:DR
First Name:MARYELLEN
Middle Name:KOCH
Last Name:JENSEN
Suffix:
Gender:F
Credentials:DC, MSED, BCBA, LBA
Other - Prefix:DR
Other - First Name:MARYELLEN
Other - Middle Name:C
Other - Last Name:KOCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:430 WAYNE 375
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63967-8938
Mailing Address - Country:US
Mailing Address - Phone:660-341-1105
Mailing Address - Fax:
Practice Address - Street 1:606 S HALLIBURTON ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-3712
Practice Address - Country:US
Practice Address - Phone:660-341-1105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000148952111NN1001X
MO2018037916103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No111NN1001XChiropractic ProvidersChiropractorNutrition