Healthcare Provider Details

I. General information

NPI: 1235338617
Provider Name (Legal Business Name): JEREMY CLINT HONNOLL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2007
Last Update Date: 09/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N CHOCTAW AVE
EL RENO OK
73036-2624
US

IV. Provider business mailing address

300 N PEBBLE CREEK TER APT 203
MUSTANG OK
73064-4174
US

V. Phone/Fax

Practice location:
  • Phone: 405-262-3209
  • Fax:
Mailing address:
  • Phone: 405-550-8736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: