Provider Demographics
NPI:1992024129
Name:PETERS, JACOB LYNN
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:LYNN
Last Name:PETERS
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:HC 60 BOX 1320
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:OK
Mailing Address - Zip Code:74536-9610
Mailing Address - Country:US
Mailing Address - Phone:918-569-4168
Mailing Address - Fax:
Practice Address - Street 1:HC 60 BOX 1320
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:OK
Practice Address - Zip Code:74536-9610
Practice Address - Country:US
Practice Address - Phone:918-569-4168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-27
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst