Healthcare Provider Details

I. General information

NPI: 1346879384
Provider Name (Legal Business Name): JACOB LOESCHE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 12/26/2023
Certification Date: 12/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 PLEASANT VALLEY RD
OWENSBORO KY
42303-9811
US

IV. Provider business mailing address

650 JOEL DR
FORT CAMPBELL KY
42223-5318
US

V. Phone/Fax

Practice location:
  • Phone: 270-417-5911
  • Fax: 270-417-6497
Mailing address:
  • Phone: 270-798-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number58072
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberT5965
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: