Provider Demographics
NPI:1487782165
Name:WILCOX, JACOB (DOM)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:WILCOX
Suffix:
Gender:M
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 PERIWINKLE PL
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-1389
Mailing Address - Country:US
Mailing Address - Phone:505-210-2781
Mailing Address - Fax:585-381-6188
Practice Address - Street 1:1301 S SAINT FRANCIS DR STE C
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4042
Practice Address - Country:US
Practice Address - Phone:505-210-2781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2722171100000X
NM1143171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist