Healthcare Provider Details

I. General information

NPI: 1609937598
Provider Name (Legal Business Name): LOREN HENNING JACOBSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 MEMORIAL DR
BROKEN BOW NE
68822-1378
US

IV. Provider business mailing address

PO BOX 690
BROKEN BOW NE
68822-0690
US

V. Phone/Fax

Practice location:
  • Phone: 308-872-2486
  • Fax: 308-872-2027
Mailing address:
  • Phone: 308-872-6283
  • Fax: 308-872-2027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11678
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: