MEDICARE: DR. JOHN PATTERSON THORN PH.D.

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	103T00000X	Psychologist	125	WY
2	103T00000X	Psychologist	6317857-2501	UT

General Provider Information

NPI Number	:	1356511562
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN PATTERSON THORN PH.D.

Provider Business Mailing Address
First Line	:	PO BOX 633
Second Line	:
City	:	VICTOR
State	:	ID
Zip	:	83455-0633
Country	:	US
Telephone Number	:	307-690-6006
Fax Number	:

Provider Business Practice Location Address
First Line	:	270 VERONICA LANE
Second Line	:	SUITE C-1
City	:	JACKSON
State	:	WY
Zip	:	83001-0000
Country	:	US
Telephone Number	:	307-690-6006
Fax Number	:

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

Provider Enumeration Date	:	03/04/2008
Last Update Date	:	03/04/2008

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Directions to “ DR. JOHN PATTERSON THORN PH.D.” Practice Location

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