Provider Demographics
NPI:1578905998
Name:THOMPSON, JOHNNY R
Entity Type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:R
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 1:114 NORTH OAK ST
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601
Mailing Address - Country:US
Mailing Address - Phone:580-491-9625
Mailing Address - Fax:580-762-8700
Practice Address - Street 1:114 N OAK ST
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-4238
Practice Address - Country:US
Practice Address - Phone:580-491-9625
Practice Address - Fax:580-762-8700
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-26
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist