Provider Demographics
NPI:1265838452
Name:THOMPSON, JODI ANN
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:ANN
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:ANN
Other - Last Name:GRIMM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:7248 BAILEY RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:WA
Mailing Address - Zip Code:98236-9716
Mailing Address - Country:US
Mailing Address - Phone:360-632-5210
Mailing Address - Fax:
Practice Address - Street 1:7248 BAILEY RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:WA
Practice Address - Zip Code:98236-9716
Practice Address - Country:US
Practice Address - Phone:360-632-5210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-14
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60519322225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist