Provider Demographics
NPI:1508450149
Name:BREWER, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BREWER
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 1:1617 D ST NE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354-2743
Mailing Address - Country:US
Mailing Address - Phone:918-325-3641
Mailing Address - Fax:
Practice Address - Street 1:405 E EXCELSIOR AVE
Practice Address - Street 2:
Practice Address - City:VINITA
Practice Address - State:OK
Practice Address - Zip Code:74301-4226
Practice Address - Country:US
Practice Address - Phone:918-256-6476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-24
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK0HG71Medicaid