Provider Demographics
NPI:1124040290
Name:JACOBS, REGINA RENEE (PT)
Entity type:Individual
Prefix:MS
First Name:REGINA
Middle Name:RENEE
Last Name:JACOBS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:REGINA
Other - Middle Name:RENEE
Other - Last Name:HOLLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 746
Mailing Address - Street 2:
Mailing Address - City:HARRAH
Mailing Address - State:OK
Mailing Address - Zip Code:73045
Mailing Address - Country:US
Mailing Address - Phone:405-454-0010
Mailing Address - Fax:405-454-0030
Practice Address - Street 1:19629 NE 23RD ST
Practice Address - Street 2:
Practice Address - City:HARRAH
Practice Address - State:OK
Practice Address - Zip Code:73045
Practice Address - Country:US
Practice Address - Phone:405-454-0010
Practice Address - Fax:405-454-0030
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3653174400000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist