Provider Demographics
NPI:1811237159
Name:THOMPSON, JARVIS L (MS)
Entity Type:Individual
Prefix:
First Name:JARVIS
Middle Name:L
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 W GARY ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-6825
Mailing Address - Country:US
Mailing Address - Phone:918-406-9472
Mailing Address - Fax:
Practice Address - Street 1:1803 S WOOD DR
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-6825
Practice Address - Country:US
Practice Address - Phone:918-756-9187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-24
Last Update Date:2013-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health