| Doctor Name: | JACK L KOCH |
| NPI Number: | 1184742074 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | L.C.P.C. |
| License Number: | |
| Business Practice Address: | 580 8th St Carlyle, IL - 622311803 |
| Business Phone Number: | 6185944581 |
| Business Fax Number: | |
| Mailing Address: | 23412 Brink Rd, CARLYLE |
| State: | IL |
| Postal Code: | 622314032 |
| Phone Number: | 6185944067 |
| Fax Number: | |
| NPI Enumeration Date: | 03/27/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YM0800X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Mental Health |
| Taxonomy Definition: | |