Provider Demographics
NPI:1669875324
Name:THOMPSON, JESSICA (OT)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12127 HIGHWAY 14 N
Mailing Address - Street 2:
Mailing Address - City:CEDAR CREST
Mailing Address - State:NM
Mailing Address - Zip Code:87008-9461
Mailing Address - Country:US
Mailing Address - Phone:505-286-3678
Mailing Address - Fax:
Practice Address - Street 1:12127 HIGHWAY 14 N
Practice Address - Street 2:
Practice Address - City:CEDAR CREST
Practice Address - State:NM
Practice Address - Zip Code:87008-9461
Practice Address - Country:US
Practice Address - Phone:505-286-3678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-08
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1405225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist