Provider Demographics
NPI:1659354033
Name:THOMPSON, KATHRYN JO (OTR)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:JO
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2255
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:TX
Mailing Address - Zip Code:78381-2255
Mailing Address - Country:US
Mailing Address - Phone:361-729-0652
Mailing Address - Fax:361-729-9508
Practice Address - Street 1:702 E MIMOSA ST
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:TX
Practice Address - Zip Code:78382-4151
Practice Address - Country:US
Practice Address - Phone:361-729-0652
Practice Address - Fax:361-729-9508
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100825174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX659640OtherBCBS
TX00830HMedicare ID - Type UnspecifiedOT
TX100825Medicare UPIN