Provider Demographics
NPI:1124261888
Name:BRODRICK, JONATHAN
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:BRODRICK
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 1:1109 6TH NW
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354
Mailing Address - Country:US
Mailing Address - Phone:918-533-8770
Mailing Address - Fax:
Practice Address - Street 1:405 E EXCELSIOR AVE
Practice Address - Street 2:
Practice Address - City:VINITA
Practice Address - State:OK
Practice Address - Zip Code:74301-4226
Practice Address - Country:US
Practice Address - Phone:918-256-6476
Practice Address - Fax:918-256-3628
Is Sole Proprietor?:No
Enumeration Date:2009-04-10
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health