Provider Demographics
NPI:1508531310
Name:UNSICKER, JACOB CHARLES (PA STUDENT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:CHARLES
Last Name:UNSICKER
Suffix:
Gender:M
Credentials:PA STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1729 S XANTHUS AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5323
Mailing Address - Country:US
Mailing Address - Phone:405-593-9244
Mailing Address - Fax:
Practice Address - Street 1:4502 E 41ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2536
Practice Address - Country:US
Practice Address - Phone:918-660-3842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-12
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK4947363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant