Provider Demographics
NPI:1588291306
Name:LOITZ, JAKE
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:LOITZ
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 1:1822 FRANCISCO ST APT 22
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-1352
Mailing Address - Country:US
Mailing Address - Phone:801-376-8223
Mailing Address - Fax:
Practice Address - Street 1:975 SERENO DRIVE
Practice Address - Street 2:FAMILY MEDICINE DEPARTMENT
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2441
Practice Address - Country:US
Practice Address - Phone:707-651-4071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No211D00000XPodiatric Medicine & Surgery Service ProvidersAssistant, Podiatric