MEDICARE: MR. JASON L THOMPSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	RI-T1303131110	CA
2	106H00000X	Marriage & Family Therapist	85329	CA

General Provider Information

NPI Number	:	1205274610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JASON L THOMPSON

Provider Business Mailing Address
First Line	:	560 W MAIN ST # 143C
Second Line	:	ALHAMBRA
City	:	ALHAMBRA
State	:	CA
Zip	:	91801-3374
Country	:	US
Telephone Number	:	310-882-1621
Fax Number	:

Provider Business Practice Location Address
First Line	:	655 N CENTRAL AVE
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91203-1422
Country	:	US
Telephone Number	:	424-901-3757
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2013
Last Update Date	:	05/25/2015

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