Provider Demographics
NPI:1295220127
Name:CARPENTER-THOMPSON, JAKE R (MD,PHD)
Entity Type:Individual
Prefix:DR
First Name:JAKE
Middle Name:R
Last Name:CARPENTER-THOMPSON
Suffix:
Gender:M
Credentials:MD,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 AMSTERDAM ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3410
Mailing Address - Country:US
Mailing Address - Phone:313-972-4200
Mailing Address - Fax:313-447-1102
Practice Address - Street 1:690 AMSTERDAM ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3410
Practice Address - Country:US
Practice Address - Phone:313-972-4200
Practice Address - Fax:313-447-1102
Is Sole Proprietor?:No
Enumeration Date:2018-06-23
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.072003207R00000X, 2084N0400X
MI43015051662084P0800X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry