Provider Demographics
NPI:1104366244
Name:CROWDER, JACOB THOMAS
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:THOMAS
Last Name:CROWDER
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 1:828 C ST NW
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354-4613
Mailing Address - Country:US
Mailing Address - Phone:918-540-0975
Mailing Address - Fax:
Practice Address - Street 1:21 S EIGHT TRIBES TRAIL SUITE B
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-5327
Practice Address - Country:US
Practice Address - Phone:918-387-8720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-07
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7583101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator