Provider Demographics
NPI:1740957315
Name:MCKINNEY, JACOB RYAN (PA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:RYAN
Last Name:MCKINNEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4120 W MEMORIAL RD STE 205
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-9322
Mailing Address - Country:US
Mailing Address - Phone:405-749-2992
Mailing Address - Fax:405-936-5445
Practice Address - Street 1:4120 W MEMORIAL RD STE 205
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-9322
Practice Address - Country:US
Practice Address - Phone:405-749-2992
Practice Address - Fax:405-936-5445
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK5177363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant