Healthcare Provider Details

I. General information

NPI: 1255267589
Provider Name (Legal Business Name): JACOB ROAYNE LOER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 N MAIN ST STE 103
GLEN ELLYN IL
60137-3572
US

IV. Provider business mailing address

999 N MAIN ST STE 103
GLEN ELLYN IL
60137-3572
US

V. Phone/Fax

Practice location:
  • Phone: 630-480-9188
  • Fax:
Mailing address:
  • Phone: 630-480-9188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number178.032765
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: