Provider Demographics
NPI:1740360452
Name:THOMPSON, JEFFREY (PA)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1020
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95201
Mailing Address - Country:US
Mailing Address - Phone:209-468-6937
Mailing Address - Fax:209-468-7042
Practice Address - Street 1:500 W. HOSPITAL RD.
Practice Address - Street 2:
Practice Address - City:FRENCH CAMP
Practice Address - State:CA
Practice Address - Zip Code:95231
Practice Address - Country:US
Practice Address - Phone:209-468-6837
Practice Address - Fax:209-468-7042
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11062363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA11062OtherLICENSE