Provider Demographics
NPI:1740603323
Name:KOCH, JESSICA (LPN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:KOCH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:865 RIDGEMONT DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-3602
Mailing Address - Country:US
Mailing Address - Phone:262-342-5022
Mailing Address - Fax:
Practice Address - Street 1:865 RIDGEMONT DR
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-3602
Practice Address - Country:US
Practice Address - Phone:262-342-5022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-02
Last Update Date:2014-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI312897-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse