Provider Demographics
NPI:1972561702
Name:COUCH, JILL KRISTEN (DO)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:KRISTEN
Last Name:COUCH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 MED TECH PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2579
Mailing Address - Country:US
Mailing Address - Phone:423-302-6565
Mailing Address - Fax:
Practice Address - Street 1:100 15TH ST NW STE 307
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-1616
Practice Address - Country:US
Practice Address - Phone:276-679-9002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102201652207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ024040Medicaid
VA1972561702Medicaid
VA1972561702Medicaid
VAVVH981AMedicare PIN