Provider Demographics
NPI:1699389916
Name:ARRISONTZ, JEREMY MCCANDOR
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:MCCANDOR
Last Name:ARRISONTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JEREMY
Other - Middle Name:MCCANDOR
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1125 NW 47TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-5230
Mailing Address - Country:US
Mailing Address - Phone:054-905-1341
Mailing Address - Fax:
Practice Address - Street 1:620 NW 5TH ST STE D
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-3947
Practice Address - Country:US
Practice Address - Phone:405-208-4469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-03
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 171M00000X
OK104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator