Provider Demographics
NPI:1023993094
Name:ROBERTS, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:ROBERTS
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 1:27427 E 109TH ST S
Mailing Address - Street 2:
Mailing Address - City:COWETA
Mailing Address - State:OK
Mailing Address - Zip Code:74429-3442
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27427 E 109TH ST S
Practice Address - Street 2:
Practice Address - City:COWETA
Practice Address - State:OK
Practice Address - Zip Code:74429-3442
Practice Address - Country:US
Practice Address - Phone:918-617-1978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-08
Last Update Date:2025-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0121828163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine