Provider Demographics
NPI:1184742074
Name:KOCH, JACK L (LCPC)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:L
Last Name:KOCH
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23412 BRINK RD
Mailing Address - Street 2:
Mailing Address - City:CARLYLE
Mailing Address - State:IL
Mailing Address - Zip Code:62231-4032
Mailing Address - Country:US
Mailing Address - Phone:618-594-4067
Mailing Address - Fax:
Practice Address - Street 1:580 8TH ST
Practice Address - Street 2:
Practice Address - City:CARLYLE
Practice Address - State:IL
Practice Address - Zip Code:62231-1803
Practice Address - Country:US
Practice Address - Phone:618-594-4581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health