Basic Information
| Provider Information | |||||||||
| NPI: | 1235338617 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HONNOLL | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | CLINT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 N PEBBLE CREEK TER APT 203 | ||||||||
| Address2: | |||||||||
| City: | MUSTANG | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730644174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055508736 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 N CHOCTAW AVE | ||||||||
| Address2: | |||||||||
| City: | EL RENO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730362624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052623209 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2007 | ||||||||
| LastUpdateDate: | 09/24/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.