Provider Demographics
NPI:1902863897
Name:THOMPSON, JAY CHENOWETH JR (MED, ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:JAY
Middle Name:CHENOWETH
Last Name:THOMPSON
Suffix:JR
Gender:M
Credentials:MED, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2028 MEADOWSIDE DR
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-2331
Mailing Address - Country:US
Mailing Address - Phone:407-739-8047
Mailing Address - Fax:
Practice Address - Street 1:1401 W MEADOWS AVE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5643
Practice Address - Country:US
Practice Address - Phone:352-787-5047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 17662255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer