Provider Demographics
NPI:1992160295
Name:JACOBS, KEITH ERIC (BA, CMII)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:ERIC
Last Name:JACOBS
Suffix:
Gender:M
Credentials:BA, CMII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12978
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73157-2978
Mailing Address - Country:US
Mailing Address - Phone:405-858-1700
Mailing Address - Fax:405-858-1700
Practice Address - Street 1:2617 GENERAL PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73107-6437
Practice Address - Country:US
Practice Address - Phone:405-858-1700
Practice Address - Fax:405-858-1770
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)