Provider Demographics
NPI:1790105062
Name:COUCH, JENNY V
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:V
Last Name:COUCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24906 W BOONE DR
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85193-8268
Mailing Address - Country:US
Mailing Address - Phone:520-405-7575
Mailing Address - Fax:
Practice Address - Street 1:24906 W BOONE DR
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85193-8268
Practice Address - Country:US
Practice Address - Phone:520-405-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-24
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-12004101YP2500X
60569101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional