Healthcare Provider Details

I. General information

NPI: 1790873180
Provider Name (Legal Business Name): JACOB BANNET MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 11/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 ALAMEDA ST
NORMAN OK
73071-5229
US

IV. Provider business mailing address

2501 SMOKING OAK RD
NORMAN OK
73072-6713
US

V. Phone/Fax

Practice location:
  • Phone: 405-573-3955
  • Fax: 405-573-3966
Mailing address:
  • Phone: 405-360-8783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number18892
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number18892
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number18892
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: