Healthcare Provider Details

I. General information

NPI: 1699389916
Provider Name (Legal Business Name): JEREMY MCCANDOR ARRISONTZ LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JEREMY MCCANDOR HARRIS

II. Dates (important events)

Enumeration Date: 09/03/2020
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105365 S HIGHWAY 102
MCLOUD OK
74851-3051
US

IV. Provider business mailing address

1 05365 S HIGHWAY 102
MCLOUD OK
74851-3051
US

V. Phone/Fax

Practice location:
  • Phone: 405-964-2081
  • Fax:
Mailing address:
  • Phone: 405-964-2081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: