Healthcare Provider Details

I. General information

NPI: 1720312549
Provider Name (Legal Business Name): JERILYN THOMPSON RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2009
Last Update Date: 09/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3451 E 12TH ST
OAKLAND CA
94601-3425
US

IV. Provider business mailing address

1601 FRUITVALE AVE
OAKLAND CA
94601-2418
US

V. Phone/Fax

Practice location:
  • Phone: 510-535-4000
  • Fax: 510-535-4128
Mailing address:
  • Phone: 510-535-4000
  • Fax: 510-535-4128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberRDH24429
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: