Provider Demographics
NPI:1043800428
Name:LACY, JEREMY JON
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:JON
Last Name:LACY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6306 COX AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73149-5118
Mailing Address - Country:US
Mailing Address - Phone:405-226-6784
Mailing Address - Fax:
Practice Address - Street 1:2808 NW 31ST ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-7407
Practice Address - Country:US
Practice Address - Phone:405-848-7555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist