Provider Demographics
NPI:1215371463
Name:THOMPSON, JACOB (PHARMD, MS)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:PHARMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 NW 12TH AVE APT 402
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3070
Mailing Address - Country:US
Mailing Address - Phone:217-521-5253
Mailing Address - Fax:
Practice Address - Street 1:930 NW 12TH AVE APT 402
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3070
Practice Address - Country:US
Practice Address - Phone:217-521-5253
Practice Address - Fax:217-521-5253
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-18
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY055190183500000X
OH03-3-29033-3183500000X
IL051-292451183500000X
OR0013977183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist