Provider Demographics
NPI:1619673811
Name:THOMPSON, RICQUAEL JADE
Entity Type:Individual
Prefix:
First Name:RICQUAEL
Middle Name:JADE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 MAPLE HILL DR
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44022-4210
Mailing Address - Country:US
Mailing Address - Phone:330-474-1020
Mailing Address - Fax:
Practice Address - Street 1:79 MAPLE HILL DR
Practice Address - Street 2:
Practice Address - City:CHAGRIN FALLS
Practice Address - State:OH
Practice Address - Zip Code:44022-4210
Practice Address - Country:US
Practice Address - Phone:330-474-1020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-31
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical