Provider Demographics
NPI:1609871714
Name:JACOB, LORETTA MARIE (CRNP)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:MARIE
Last Name:JACOB
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 636988
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6988
Mailing Address - Country:US
Mailing Address - Phone:888-940-2722
Mailing Address - Fax:513-632-8898
Practice Address - Street 1:1995 E STATE ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OH
Practice Address - Zip Code:44460-2423
Practice Address - Country:US
Practice Address - Phone:330-480-2199
Practice Address - Fax:330-480-2071
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP04783363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2161360Medicaid
OHS78798Medicare UPIN
OHJANP02713Medicare PIN