Provider Demographics
NPI:1265141253
Name:WILLIAMS, JACOB EARL
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:EARL
Last Name:WILLIAMS
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 1:20907 E 34TH PL S
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-5108
Mailing Address - Country:US
Mailing Address - Phone:918-852-0110
Mailing Address - Fax:
Practice Address - Street 1:6305 E 120TH CT UNIT D
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-8810
Practice Address - Country:US
Practice Address - Phone:918-852-0110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-17
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4480111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor