Healthcare Provider Details

I. General information

NPI: 1497802987
Provider Name (Legal Business Name): JACQUELINE ANNE THOMPSON RD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 07/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 NEILSON ST SUITE 201
WATSONVILLE CA
95076-2485
US

IV. Provider business mailing address

3010 CONCORD CT
MARINA CA
93933-4003
US

V. Phone/Fax

Practice location:
  • Phone: 831-763-6445
  • Fax: 831-724-0877
Mailing address:
  • Phone: 831-277-6283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number883567
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: