Provider Demographics
NPI:1942574793
Name:SLAGLE, JACOB AUSTIN (MSBS)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:AUSTIN
Last Name:SLAGLE
Suffix:
Gender:M
Credentials:MSBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1908 NW LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-5029
Mailing Address - Country:US
Mailing Address - Phone:580-591-1912
Mailing Address - Fax:
Practice Address - Street 1:807 SW F AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-4506
Practice Address - Country:US
Practice Address - Phone:580-591-1912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-25
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OK103TR0400X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation