Provider Demographics
NPI:1336582006
Name:DUNN, JERALD L (CM)
Entity type:Individual
Prefix:
First Name:JERALD
Middle Name:L
Last Name:DUNN
Suffix:
Gender:M
Credentials:CM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 N SHARTEL AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73103-2403
Mailing Address - Country:US
Mailing Address - Phone:450-702-6677
Mailing Address - Fax:
Practice Address - Street 1:1305 N SHARTEL AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-2403
Practice Address - Country:US
Practice Address - Phone:450-702-6677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-12
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK205864448Medicaid