Provider Demographics
NPI:1083093678
Name:EDWARDS, JACOB (DC)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6401 N INTERSTATE DR
Mailing Address - Street 2:SUITE 148
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-9515
Mailing Address - Country:US
Mailing Address - Phone:405-801-3665
Mailing Address - Fax:
Practice Address - Street 1:6401 N INTERSTATE DR
Practice Address - Street 2:SUITE 148
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-9515
Practice Address - Country:US
Practice Address - Phone:405-801-3665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-28
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4198111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor