Basic Information
| Provider Information | |||||||||
| NPI: | 1588172985 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBUS | ||||||||
| FirstName: | LOREN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15026 DECLARATION DR | ||||||||
| Address2: | |||||||||
| City: | WESTFIELD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460748081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174089989 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14535A HAZEL DELL PKWY | ||||||||
| Address2: | |||||||||
| City: | CARMEL | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460339401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177054360 | ||||||||
| FaxNumber: | 3177054361 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2018 | ||||||||
| LastUpdateDate: | 02/21/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 28133889A | IN | N | Nursing Service Providers | Registered Nurse | 363L00000X | 71008114A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 300016056 | 05 | IN | MEDICAID |