Healthcare Provider Details

I. General information

NPI: 1952079758
Provider Name (Legal Business Name): JACOB THOMAS DUVALL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2021
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N PORTER AVE STE 110
NORMAN OK
73071-6426
US

IV. Provider business mailing address

3160 ROCK CREEK TRL APT 1712
NORMAN OK
73072-2536
US

V. Phone/Fax

Practice location:
  • Phone: 405-424-7711
  • Fax:
Mailing address:
  • Phone: 405-210-0384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: