Provider Demographics
NPI:1124187935
Name:THOMPSON, JACQUELYN KAY (PHD , LP, MSE)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:KAY
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:PHD , LP, MSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 ORCHARD LN
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-5330
Mailing Address - Country:US
Mailing Address - Phone:651-338-8702
Mailing Address - Fax:651-777-3692
Practice Address - Street 1:1920 ORCHARD LN
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-5330
Practice Address - Country:US
Practice Address - Phone:651-338-8702
Practice Address - Fax:651-777-3692
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2495103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6466885300OtherMN. HEALTHCARE PROGRAMS
MN6172268OtherUNITED BEHAVORAL HEALTH