Provider Demographics
NPI:1174646947
Name:THOMPSON, JOAN R (REGISTERED DIETITIAN)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:R
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 FRUITVALE AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-2322
Mailing Address - Country:US
Mailing Address - Phone:510-535-4000
Mailing Address - Fax:510-535-4128
Practice Address - Street 1:3451 E 12TH STREET
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601
Practice Address - Country:US
Practice Address - Phone:510-535-3700
Practice Address - Fax:510-535-4216
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA814574133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHAP71021FOtherFPACT
CA55-1975OtherFQHC MEDICARE PART A
CAZZZ29799ZOtherFQHC MEDICARE PART B
CAFHC71021FMedicaid