Provider Demographics
NPI:1376141994
Name:THOMPSON, JONATHAN D (LMBT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 N HAYNE ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28112-4856
Mailing Address - Country:US
Mailing Address - Phone:704-441-1600
Mailing Address - Fax:
Practice Address - Street 1:215 N HAYNE ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-4856
Practice Address - Country:US
Practice Address - Phone:704-441-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16866225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist