Provider Demographics
NPI:1649869579
Name:CLEVELAND, JEREMIAH THOMAS
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:THOMAS
Last Name:CLEVELAND
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 1:109 S HARRILL AVE
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-5317
Mailing Address - Country:US
Mailing Address - Phone:918-370-4922
Mailing Address - Fax:
Practice Address - Street 1:109 S HARRILL AVE
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-5317
Practice Address - Country:US
Practice Address - Phone:918-370-4922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor