Provider Demographics
NPI:1588172985
Name:JACOBUS, LOREN K (NP)
Entity type:Individual
Prefix:
First Name:LOREN
Middle Name:K
Last Name:JACOBUS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15026 DECLARATION DR
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-8081
Mailing Address - Country:US
Mailing Address - Phone:317-408-9989
Mailing Address - Fax:
Practice Address - Street 1:14535A HAZEL DELL PKWY
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46033-9401
Practice Address - Country:US
Practice Address - Phone:317-705-4360
Practice Address - Fax:317-705-4361
Is Sole Proprietor?:No
Enumeration Date:2018-01-19
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28133889A163W00000X
IN71008114A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300016056Medicaid