Provider Demographics
NPI:1205165784
Name:KOCH, JACOB JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:JOHN
Last Name:KOCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 FOGGY CUT LN
Mailing Address - Street 2:
Mailing Address - City:LANDRUM
Mailing Address - State:SC
Mailing Address - Zip Code:29356-3145
Mailing Address - Country:US
Mailing Address - Phone:864-895-5599
Mailing Address - Fax:
Practice Address - Street 1:4020 FOLKER ST
Practice Address - Street 2:ALASKA COMMUNITY MENTAL HEALTH SERVICE
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:97508
Practice Address - Country:US
Practice Address - Phone:864-895-5599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-14
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010233252084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry