Healthcare Provider Details

I. General information

NPI: 1942540398
Provider Name (Legal Business Name): JACOB RUSSELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2013
Last Update Date: 02/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 12TH AVE NE
NORMAN OK
73071-5238
US

IV. Provider business mailing address

1840 W BOYD ST
NORMAN OK
73069-4828
US

V. Phone/Fax

Practice location:
  • Phone: 405-573-3842
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: