Provider Demographics
NPI:1104885086
Name:KOEPSEL, JO S (PMHWP)
Entity type:Individual
Prefix:
First Name:JO
Middle Name:S
Last Name:KOEPSEL
Suffix:
Gender:F
Credentials:PMHWP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5440 OLD BROWNSVILLE RD.
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78417
Mailing Address - Country:US
Mailing Address - Phone:361-452-1151
Mailing Address - Fax:361-452-1517
Practice Address - Street 1:5440 OLD BROWNSVILLE RD.
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78417
Practice Address - Country:US
Practice Address - Phone:361-452-1151
Practice Address - Fax:361-452-1517
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX232350363LP0808X, 363LF0000X
TXAP105046363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8H8660OtherBC/BS OF TX
TX038062801Medicaid
TX038062802Medicaid
TX80N959Medicare PIN
TX8H8660OtherBC/BS OF TX
TX038062802Medicaid