Provider Demographics
NPI:1912004888
Name:THOMAS, JACK ROBERT (MA)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:ROBERT
Last Name:THOMAS
Suffix:
Gender:M
Credentials:MA
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 1307
Mailing Address - Street 2:
Mailing Address - City:LA CONNER
Mailing Address - State:WA
Mailing Address - Zip Code:98257-1307
Mailing Address - Country:US
Mailing Address - Phone:360-466-0130
Mailing Address - Fax:
Practice Address - Street 1:1100 S 2ND ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-4209
Practice Address - Country:US
Practice Address - Phone:364-193-5513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00036751101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health