=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598790024
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COREY DUANE JACOBS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2006
-----------------------------------------------------
Last Update Date | 09/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 W 1ST ST STE 101
-----------------------------------------------------
City | ELK CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73644-3133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-225-2516
-----------------------------------------------------
Fax | 580-303-5830
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1800 W 1ST ST STE 101
-----------------------------------------------------
City | ELK CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73644-3133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-225-2516
-----------------------------------------------------
Fax | 580-303-5830
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | M-15890
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 27305
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------