Provider Demographics
NPI:1891038105
Name:THOMPSON, JENNIFER LEIGH
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LEIGH
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 1:1600 JOHN ADAMS PKWY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4300
Mailing Address - Country:US
Mailing Address - Phone:208-529-5276
Mailing Address - Fax:208-529-6506
Practice Address - Street 1:1600 JOHN ADAMS PKWY
Practice Address - Street 2:SUITE 102
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4300
Practice Address - Country:US
Practice Address - Phone:208-529-5276
Practice Address - Fax:208-529-6506
Is Sole Proprietor?:No
Enumeration Date:2013-04-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-28471104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker