Provider Demographics
NPI:1467928184
Name:THOMAS, JEAN DAVID (FNP)
Entity Type:Individual
Prefix:MR
First Name:JEAN
Middle Name:DAVID
Last Name:THOMAS
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 CONGRESS ST STE 513
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-5523
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:SALEM FAMILY HEALTH CENTER
Practice Address - Street 2:47 CONGRESS STREET
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970
Practice Address - Country:US
Practice Address - Phone:978-744-8388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-20
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2269800363L00000X, 363LP0808X, 363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110149360AMedicaid