Healthcare Provider Details

I. General information

NPI: 1992024129
Provider Name (Legal Business Name): MR. JACOB LYNN PETERS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2010
Last Update Date: 05/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HC 60 BOX 1320
CLAYTON OK
74536-9610
US

IV. Provider business mailing address

HC 60 BOX 1320
CLAYTON OK
74536-9610
US

V. Phone/Fax

Practice location:
  • Phone: 918-569-4168
  • Fax:
Mailing address:
  • Phone: 918-569-4168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: