Healthcare Provider Details

I. General information

NPI: 1508531310
Provider Name (Legal Business Name): JACOB CHARLES UNSICKER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2021
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 NE 13TH ST
OKLAHOMA CITY OK
73104-5004
US

IV. Provider business mailing address

2408 CREEKVIEW TRL
MOORE OK
73160-2186
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-5321
  • Fax:
Mailing address:
  • Phone: 405-593-9244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4947
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: