Provider Demographics
NPI:1972035145
Name:BROWN, JACOB C (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:C
Last Name:BROWN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 SE 51ST ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73135-4202
Mailing Address - Country:US
Mailing Address - Phone:479-966-0882
Mailing Address - Fax:
Practice Address - Street 1:5300 SE 29TH ST
Practice Address - Street 2:
Practice Address - City:DEL CITY
Practice Address - State:OK
Practice Address - Zip Code:73115-4702
Practice Address - Country:US
Practice Address - Phone:405-835-2770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA2738363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant