1376226977 NPI number — MS. JACQUELINE KAY LOUTZENHEISER PA-C

Table of content: MS. JACQUELINE KAY LOUTZENHEISER PA-C (NPI 1376226977)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376226977 NPI number — MS. JACQUELINE KAY LOUTZENHEISER PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOUTZENHEISER
Provider First Name:
JACQUELINE
Provider Middle Name:
KAY
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LOUTZENHEISER
Provider Other First Name:
JACKIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1376226977
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3500 CHAD DRIVE STE 300, EUGENE OREGON 97408
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EUGENE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-687-5443
Provider Business Mailing Address Fax Number:
541-683-1422

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
520 COUNTRY CLUB ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUGENE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-683-5001
Provider Business Practice Location Address Fax Number:
541-683-1422
Provider Enumeration Date:
08/09/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA217062 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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