Provider Demographics
NPI:1497455901
Name:THOMPSON, JONATHAN DERELL
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DERELL
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 1:6780 FORTINO ST APT 206
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-6609
Mailing Address - Country:US
Mailing Address - Phone:512-848-5908
Mailing Address - Fax:
Practice Address - Street 1:1119 W FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-5663
Practice Address - Country:US
Practice Address - Phone:507-774-3075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-06
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MND14966122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program