Healthcare Provider Details

I. General information

NPI: 1619243185
Provider Name (Legal Business Name): MARIA JEANNETTE THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: M JEANNETTE THOMAS

II. Dates (important events)

Enumeration Date: 03/28/2012
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 CUMMINS DR
MODESTO CA
95358-6400
US

IV. Provider business mailing address

1600 GALVEZ AVE
MODESTO CA
95355-2516
US

V. Phone/Fax

Practice location:
  • Phone: 209-622-1420
  • Fax: 209-491-0627
Mailing address:
  • Phone: 209-303-8465
  • Fax: 209-491-0627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-UHWQSX
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: