Provider Demographics
NPI:1881966992
Name:KOO, JESSICA H
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:H
Last Name:KOO
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 1:1025 RESCOBIE CT
Mailing Address - Street 2:
Mailing Address - City:SCHERERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46375-2977
Mailing Address - Country:US
Mailing Address - Phone:219-322-4647
Mailing Address - Fax:219-322-4647
Practice Address - Street 1:8001 BROADWAY
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-5500
Practice Address - Country:US
Practice Address - Phone:219-736-8067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-04
Last Update Date:2012-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26016170A183500000X
IL051037814183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist