1568746964 NPI number — MRS. JACQUELINE LEIGH KOCKEN DPT

Table of content: MRS. JACQUELINE LEIGH KOCKEN DPT (NPI 1568746964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568746964 NPI number — MRS. JACQUELINE LEIGH KOCKEN DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOCKEN
Provider First Name:
JACQUELINE
Provider Middle Name:
LEIGH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568746964
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11940 ALPHARETTA HWY
Provider Second Line Business Mailing Address:
150
Provider Business Mailing Address City Name:
ALPHARETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30009-2003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-754-0085
Provider Business Mailing Address Fax Number:
770-754-9288

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11940 ALPHARETTA HWY
Provider Second Line Business Practice Location Address:
150
Provider Business Practice Location Address City Name:
ALPHARETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30009-2003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-754-0085
Provider Business Practice Location Address Fax Number:
770-754-9288
Provider Enumeration Date:
10/04/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT 010461 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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