Provider Demographics
NPI:1962392126
Name:MOORE, JACOB EZRA
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:EZRA
Last Name:MOORE
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 1:18301 HORSESHOE DR
Mailing Address - Street 2:
Mailing Address - City:JONES
Mailing Address - State:OK
Mailing Address - Zip Code:73049-8124
Mailing Address - Country:US
Mailing Address - Phone:806-802-4056
Mailing Address - Fax:
Practice Address - Street 1:13913 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-7011
Practice Address - Country:US
Practice Address - Phone:405-445-5567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-08
Last Update Date:2025-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKRBT-25-450983106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician