Healthcare Provider Details

I. General information

NPI: 1104919604
Provider Name (Legal Business Name): JENNIFER J.R. LOOMIS AA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 02/28/2020
Certification Date: 02/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36000 EUCLID AVE
WILLOUGHBY OH
44094-4625
US

IV. Provider business mailing address

7757 AUBURN RD STE 15
PAINESVILLE OH
44077-9604
US

V. Phone/Fax

Practice location:
  • Phone: 440-350-0832
  • Fax: 440-354-7420
Mailing address:
  • Phone: 440-350-0832
  • Fax: 440-354-7420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number67.000123
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: