Provider Demographics
NPI:1164031704
Name:VANBRUNT, JEREMY
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:VANBRUNT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 SE 6TH ST
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-6211
Mailing Address - Country:US
Mailing Address - Phone:918-304-7323
Mailing Address - Fax:
Practice Address - Street 1:109 S HARRILL AVE
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-5317
Practice Address - Country:US
Practice Address - Phone:918-304-7323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-29
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician