Provider Demographics
NPI:1528390531
Name:HINES, JOHNATHAN B
Entity Type:Individual
Prefix:MR
First Name:JOHNATHAN
Middle Name:B
Last Name:HINES
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 1:1175 S. ASPEN AVE
Mailing Address - Street 2:SUITE I
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012
Mailing Address - Country:US
Mailing Address - Phone:918-289-2033
Mailing Address - Fax:918-806-6083
Practice Address - Street 1:1175 S. ASPEN AVE
Practice Address - Street 2:SUITE I
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012
Practice Address - Country:US
Practice Address - Phone:918-289-2033
Practice Address - Fax:918-806-6083
Is Sole Proprietor?:No
Enumeration Date:2010-02-02
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral