Provider Demographics
NPI:1013107036
Name:THOMAS, JACK E (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:E
Last Name:THOMAS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2108 S LOCUST CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-6751
Mailing Address - Country:US
Mailing Address - Phone:812-325-6877
Mailing Address - Fax:
Practice Address - Street 1:2108 S LOCUST CT
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-6751
Practice Address - Country:US
Practice Address - Phone:812-325-6877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20010356A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical