Healthcare Provider Details

I. General information

NPI: 1487782165
Provider Name (Legal Business Name): JACOB WILCOX DOM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 10/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 S SAINT FRANCIS DR STE C
SANTA FE NM
87505-4042
US

IV. Provider business mailing address

2 PERIWINKLE PL
SANTA FE NM
87508-1389
US

V. Phone/Fax

Practice location:
  • Phone: 505-210-2781
  • Fax:
Mailing address:
  • Phone: 505-210-2781
  • Fax: 585-381-6188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number2722
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1143
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: