Provider Demographics
NPI:1114670775
Name:THOMPSON, JACOB STEPHEN (DO)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:STEPHEN
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 ENTERPRISE DR UNIT 104
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-5853
Mailing Address - Country:US
Mailing Address - Phone:940-224-0041
Mailing Address - Fax:
Practice Address - Street 1:1225 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1016
Practice Address - Country:US
Practice Address - Phone:314-977-4440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program