Provider Demographics
NPI:1376226977
Name:LOUTZENHEISER, JACQUELINE KAY (PA-C)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:KAY
Last Name:LOUTZENHEISER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:LOUTZENHEISER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:2770 W NEFF ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-0348
Mailing Address - Country:US
Mailing Address - Phone:208-631-0694
Mailing Address - Fax:
Practice Address - Street 1:1460 G ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-4112
Practice Address - Country:US
Practice Address - Phone:541-726-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant