Provider Demographics
NPI:1285629402
Name:THOMPSON, TARA JO (DC)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:JO
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:TARA
Other - Middle Name:JO
Other - Last Name:LINDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:P.O. BOX 10
Mailing Address - Street 2:
Mailing Address - City:WYANET
Mailing Address - State:IL
Mailing Address - Zip Code:61379-0010
Mailing Address - Country:US
Mailing Address - Phone:815-699-7333
Mailing Address - Fax:815-699-7334
Practice Address - Street 1:102 W MAIN ST.
Practice Address - Street 2:
Practice Address - City:WYANET
Practice Address - State:IL
Practice Address - Zip Code:61379-0010
Practice Address - Country:US
Practice Address - Phone:815-699-7333
Practice Address - Fax:815-699-7334
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007591111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL350053822OtherRAILROAD MEDICARE
IL627456OtherBCBS OF IL
IL038007591Medicaid
U84046Medicare UPIN
IL038007591Medicaid
IL636780Medicare PIN