Provider Demographics
NPI:1205274610
Name:THOMPSON, JASON L
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:L
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 W MAIN ST # 143C
Mailing Address - Street 2:ALHAMBRA
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-3374
Mailing Address - Country:US
Mailing Address - Phone:310-882-1621
Mailing Address - Fax:
Practice Address - Street 1:655 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-1422
Practice Address - Country:US
Practice Address - Phone:424-901-3757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-07
Last Update Date:2015-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARI-T1303131110101YA0400X
CA85329106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist