Provider Demographics
NPI:1326317074
Name:THOMPSON, JAMIE TYRELL
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:TYRELL
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7924 GLORY ROAD
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:OK
Mailing Address - Zip Code:73084
Mailing Address - Country:US
Mailing Address - Phone:405-627-8955
Mailing Address - Fax:
Practice Address - Street 1:7924 GLORY ROAD
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:OK
Practice Address - Zip Code:73084
Practice Address - Country:US
Practice Address - Phone:405-627-8955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-27
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLT512438831850103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst