Provider Demographics
NPI:1548850621
Name:JACOBS, HEAVEN LEE (OTA)
Entity type:Individual
Prefix:
First Name:HEAVEN LEE
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 SPRING CREEK RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-1703
Mailing Address - Country:US
Mailing Address - Phone:405-822-1508
Mailing Address - Fax:
Practice Address - Street 1:224 SPRING CREEK RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-1703
Practice Address - Country:US
Practice Address - Phone:405-822-1508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-21
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1832224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant