Healthcare Provider Details

I. General information

NPI: 1891066445
Provider Name (Legal Business Name): LACEY KRISTINE JACOBS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2012
Last Update Date: 01/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11601 S. WESTERN AVE
OKLAHOMA CITY OK
73170-5823
US

IV. Provider business mailing address

524 SW 124TH PL
OKLAHOMA CITY OK
73170-6039
US

V. Phone/Fax

Practice location:
  • Phone: 405-512-6950
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberAPPA2099
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: