Provider Demographics
NPI:1245426899
Name:THOMPSON, JESSICA LYNNE (RN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNNE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 ROWE RD
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:NY
Mailing Address - Zip Code:13114-3352
Mailing Address - Country:US
Mailing Address - Phone:315-271-3252
Mailing Address - Fax:
Practice Address - Street 1:125 ROWE RD
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:NY
Practice Address - Zip Code:13114-3352
Practice Address - Country:US
Practice Address - Phone:315-271-3252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-18
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY270770164W00000X
NY684348163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02684242Medicaid