Provider Demographics
NPI:1760764047
Name:BRUNSON, JAMES GLEN
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:GLEN
Last Name:BRUNSON
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 1:800 DOLLINS ST
Mailing Address - Street 2:
Mailing Address - City:WILBURTON
Mailing Address - State:OK
Mailing Address - Zip Code:74578-3204
Mailing Address - Country:US
Mailing Address - Phone:918-448-5497
Mailing Address - Fax:
Practice Address - Street 1:800 DOLLINS ST
Practice Address - Street 2:
Practice Address - City:WILBURTON
Practice Address - State:OK
Practice Address - Zip Code:74578-3204
Practice Address - Country:US
Practice Address - Phone:918-448-5497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation