Provider Demographics
NPI:1740463256
Name:LOEHR, JACQUELINE T (RN)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:T
Last Name:LOEHR
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 OWASCO DR
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1617
Mailing Address - Country:US
Mailing Address - Phone:631-474-1258
Mailing Address - Fax:
Practice Address - Street 1:209 OWASCO DR
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1617
Practice Address - Country:US
Practice Address - Phone:631-474-1258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-07
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY425431-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY425431-1Medicaid