Provider Demographics
NPI:1164960746
Name:THOMAS, JIMMIE
Entity Type:Individual
Prefix:MR
First Name:JIMMIE
Middle Name:
Last Name:THOMAS
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 1:645 HIGHWAY 80 E
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-8527
Mailing Address - Country:US
Mailing Address - Phone:318-343-6966
Mailing Address - Fax:318-345-7123
Practice Address - Street 1:645 HIGHWAY 80 E
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-8527
Practice Address - Country:US
Practice Address - Phone:318-343-6966
Practice Address - Fax:318-345-7123
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-03
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
LA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health