Provider Demographics
NPI:1912088899
Name:KOCH, JENNIFER (CNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KOCH
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:M
Other - Last Name:WALDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1510
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54702-1510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 WEST AVE S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4783
Practice Address - Country:US
Practice Address - Phone:608-785-0940
Practice Address - Fax:608-392-9898
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI152935363LN0005X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41278700Medicaid
WI41278700Medicaid