Provider Demographics
NPI:1891234712
Name:THACKER, JOHN STEPHEN (LAC, CMTPT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:STEPHEN
Last Name:THACKER
Suffix:
Gender:M
Credentials:LAC, CMTPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 S MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-4863
Mailing Address - Country:US
Mailing Address - Phone:540-315-9763
Mailing Address - Fax:540-605-7311
Practice Address - Street 1:508 S MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-4863
Practice Address - Country:US
Practice Address - Phone:540-315-9763
Practice Address - Fax:540-605-7311
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121000432171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist