Provider Demographics
NPI:1629317078
Name:LOOSLE, JONATHAN W
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:W
Last Name:LOOSLE
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 1:1472 E IRON EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6598
Mailing Address - Country:US
Mailing Address - Phone:208-577-1188
Mailing Address - Fax:
Practice Address - Street 1:1472 E IRON EAGLE DR
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6598
Practice Address - Country:US
Practice Address - Phone:208-577-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide