Provider Demographics
NPI:1811262017
Name:THOMPSON, THADDEUS (PT)
Entity type:Individual
Prefix:
First Name:THADDEUS
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6320 SAINT AUGUSTINE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-2800
Mailing Address - Country:US
Mailing Address - Phone:904-448-5075
Mailing Address - Fax:
Practice Address - Street 1:6320 SAINT AUGUSTINE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2800
Practice Address - Country:US
Practice Address - Phone:904-448-5075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-21
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38649225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist