Basic Information
| Provider Information | |||||||||
| NPI: | 1255504791 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LORAN C JACOBS JR PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 29211 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850389211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022736770 | ||||||||
| FaxNumber: | 6028890489 | ||||||||
| Practice Location | |||||||||
| Address1: | 807 S PONDEROSA ST | ||||||||
| Address2: | |||||||||
| City: | PAYSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855415542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022736770 | ||||||||
| FaxNumber: | 6028890489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2008 | ||||||||
| LastUpdateDate: | 04/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | JACOBS | ||||||||
| AuthorizedOfficialFirstName: | LORAN | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 6022736770 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN151239 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.