Provider Demographics
NPI:1568140887
Name:JAKIELASZEK, JACOB K (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:K
Last Name:JAKIELASZEK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:957 MAYBERRY RD
Mailing Address - Street 2:
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-2621
Mailing Address - Country:US
Mailing Address - Phone:610-316-1354
Mailing Address - Fax:
Practice Address - Street 1:503 N 14TH ST
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-4655
Practice Address - Country:US
Practice Address - Phone:580-200-2282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7787122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty