Provider Demographics
NPI:1578221552
Name:THOMPSON, JAKE G (PSS-MH)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:G
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:PSS-MH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 NE 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-4630
Mailing Address - Country:US
Mailing Address - Phone:503-474-5509
Mailing Address - Fax:
Practice Address - Street 1:640 NE 3RD ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-4630
Practice Address - Country:US
Practice Address - Phone:503-474-5509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR105853OtherTRADITIONAL HEALTH WORKER