Provider Demographics
NPI:1205039955
Name:LOETHEN, JENNIFER ANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ANNE
Last Name:LOETHEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3165 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-5012
Mailing Address - Country:US
Mailing Address - Phone:309-648-6024
Mailing Address - Fax:
Practice Address - Street 1:5 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5621
Practice Address - Country:US
Practice Address - Phone:618-876-2924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-08
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036121965208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036121965Medicaid