Basic Information
| Provider Information | |||||||||
| NPI: | 1790873180 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANNET | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2501 SMOKING OAK RD | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730726713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053608783 | ||||||||
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| Practice Location | |||||||||
| Address1: | 909 ALAMEDA ST | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730715229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055733955 | ||||||||
| FaxNumber: | 4055733966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 11/10/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 18892 | OK | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0802X | 18892 | OK | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | 2084P0805X | 18892 | OK | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 100035150A | 05 | OK | MEDICAID |