Provider Demographics
NPI:1417599085
Name:BUCHANAN, JACOB OLIVER
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:OLIVER
Last Name:BUCHANAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:FAITH
Other - Last Name:BUCHANAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4100 NW 155TH ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-9139
Mailing Address - Country:US
Mailing Address - Phone:512-876-7942
Mailing Address - Fax:
Practice Address - Street 1:4100 NW 155TH ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-9139
Practice Address - Country:US
Practice Address - Phone:512-876-7942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-15
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator