Healthcare Provider Details

I. General information

NPI: 1194657254
Provider Name (Legal Business Name): JACOB LOGAN REID
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1077 COUNTY STREET 2790
POCASSET OK
73079-8020
US

IV. Provider business mailing address

1077 COUNTY STREET 2790
POCASSET OK
73079-8020
US

V. Phone/Fax

Practice location:
  • Phone: 405-476-1720
  • Fax:
Mailing address:
  • Phone: 405-476-1720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: