Provider Demographics
NPI:1609448323
Name:JACOB, RYAN MICHAEL
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MICHAEL
Last Name:JACOB
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 1:12221 S LAND AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-4509
Mailing Address - Country:US
Mailing Address - Phone:405-837-2895
Mailing Address - Fax:
Practice Address - Street 1:100 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-5207
Practice Address - Country:US
Practice Address - Phone:405-974-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer