Provider Demographics
NPI:1790873180
Name:BANNET, JACOB (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:BANNET
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 SMOKING OAK RD
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-6713
Mailing Address - Country:US
Mailing Address - Phone:405-360-8783
Mailing Address - Fax:
Practice Address - Street 1:909 ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-5229
Practice Address - Country:US
Practice Address - Phone:405-573-3955
Practice Address - Fax:405-573-3966
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK188922084P0800X, 2084P0802X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100035150AMedicaid
OK100035150AMedicaid