Provider Demographics
NPI:1215479969
Name:KOONS, JEFFREY
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:KOONS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1684 EDGERTON ST
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55117-2419
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1684 EDGERTON ST
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55117-2419
Practice Address - Country:US
Practice Address - Phone:612-414-2332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-12
Last Update Date:2016-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN174221-5163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health