Provider Demographics
NPI:1275975898
Name:HALL, JEREMIAH
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:HALL
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 S RANCHWOOD BLVD
Mailing Address - Street 2:SUITE 15 AND 16
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-2741
Mailing Address - Country:US
Mailing Address - Phone:405-354-6010
Mailing Address - Fax:
Practice Address - Street 1:300 S RANCHWOOD BLVD
Practice Address - Street 2:SUITE 15 AND 16
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-2741
Practice Address - Country:US
Practice Address - Phone:405-354-6010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-24
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health