Healthcare Provider Details

I. General information

NPI: 1033877998
Provider Name (Legal Business Name): MRS. JENNIFER L THOMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2021
Last Update Date: 04/24/2023
Certification Date: 04/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 CA-138
CRESTLINE CA
92325-9232
US

IV. Provider business mailing address

340 CA-138
CRESTLINE CA
92325-6300
US

V. Phone/Fax

Practice location:
  • Phone: 909-336-3330
  • Fax:
Mailing address:
  • Phone: 909-336-3330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13625
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: