Provider Demographics
NPI:1487076857
Name:HILL, JAKE
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:HILL
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 1:23899 STATE HIGHWAY 74
Mailing Address - Street 2:
Mailing Address - City:PURCELL
Mailing Address - State:OK
Mailing Address - Zip Code:73080-6964
Mailing Address - Country:US
Mailing Address - Phone:405-253-3838
Mailing Address - Fax:
Practice Address - Street 1:23899 STATE HIGHWAY 74
Practice Address - Street 2:
Practice Address - City:PURCELL
Practice Address - State:OK
Practice Address - Zip Code:73080-6964
Practice Address - Country:US
Practice Address - Phone:405-253-3838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-20
Last Update Date:2014-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKYUP833152728OtherBLUE CROSS BLUE SHIELD