Healthcare Provider Details

I. General information

NPI: 1841819794
Provider Name (Legal Business Name): JACOB SAMUEL FORBES DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2020
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3580 W 9000 S
WEST JORDAN UT
84088-8812
US

IV. Provider business mailing address

4 E CLARK BASS BLVD STE 301
MCALESTER OK
74501-4269
US

V. Phone/Fax

Practice location:
  • Phone: 801-561-8888
  • Fax:
Mailing address:
  • Phone: 918-421-6081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7293
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1329004-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: