Healthcare Provider Details

I. General information

NPI: 1972174217
Provider Name (Legal Business Name): JACOB WILLIAM THOMPSON DNP, CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2021
Last Update Date: 07/19/2024
Certification Date: 07/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19820 N 7TH ST
PHOENIX AZ
85024-1689
US

IV. Provider business mailing address

19820 N 7TH ST STE 208
PHOENIX AZ
85024-1694
US

V. Phone/Fax

Practice location:
  • Phone: 623-320-0660
  • Fax:
Mailing address:
  • Phone: 623-320-0660
  • Fax: 623-320-0670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number309108
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: