Provider Demographics
NPI:1366992190
Name:KOCH, JESSICA (NP-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:KOCH
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 SUGARLOAF PKWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-5518
Mailing Address - Country:US
Mailing Address - Phone:678-710-2727
Mailing Address - Fax:
Practice Address - Street 1:3330 SUGARLOAF PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-5518
Practice Address - Country:US
Practice Address - Phone:678-710-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-05
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN213005363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily