Provider Demographics
NPI:1770204364
Name:SHELLY JACOBS MD PLLC
Entity type:Organization
Organization Name:SHELLY JACOBS MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KHANG
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-532-3176
Mailing Address - Street 1:6424 N PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-2012
Mailing Address - Country:US
Mailing Address - Phone:405-757-4643
Mailing Address - Fax:
Practice Address - Street 1:6424 N PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-2012
Practice Address - Country:US
Practice Address - Phone:405-757-4643
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility