Provider Demographics
NPI:1407219207
Name:LOVELESS, JACOB
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:
Last Name:LOVELESS
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 1:8216 M.5 RD
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:MI
Mailing Address - Zip Code:49837-9078
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8216 M.5 RD
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:MI
Practice Address - Zip Code:49837-9078
Practice Address - Country:US
Practice Address - Phone:906-399-9928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program