Healthcare Provider Details

I. General information

NPI: 1710654561
Provider Name (Legal Business Name): JOHN WASHINGTON THOMPSON JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2021
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6330 THORNTON AVE
NEWARK CA
94560-3734
US

IV. Provider business mailing address

10873 PACKARD ST
OAKLAND CA
94603-3260
US

V. Phone/Fax

Practice location:
  • Phone: 510-792-4357
  • Fax:
Mailing address:
  • Phone: 510-207-4007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberR1437370721
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: