Provider Demographics
NPI:1811703754
Name:HILLIS, JACOB TAYLOR
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:TAYLOR
Last Name:HILLIS
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 1:25293 STATE HIGHWAY 59
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:OK
Mailing Address - Zip Code:73095-3301
Mailing Address - Country:US
Mailing Address - Phone:405-919-2675
Mailing Address - Fax:
Practice Address - Street 1:25293 STATE HIGHWAY 59
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:OK
Practice Address - Zip Code:73095-3301
Practice Address - Country:US
Practice Address - Phone:405-919-2675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program