Provider Demographics
NPI:1235338617
Name:HONNOLL, JEREMY CLINT
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:CLINT
Last Name:HONNOLL
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 1:300 N PEBBLE CREEK TER APT 203
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-4174
Mailing Address - Country:US
Mailing Address - Phone:405-550-8736
Mailing Address - Fax:
Practice Address - Street 1:200 N CHOCTAW AVE
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036-2624
Practice Address - Country:US
Practice Address - Phone:405-262-3209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-16
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health