Healthcare Provider Details

I. General information

NPI: 1982274858
Provider Name (Legal Business Name): JORDAN T THOMPSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2021
Last Update Date: 07/01/2021
Certification Date: 06/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9614 UNIVERSITY AVE APT 201H
CEDAR FALLS IA
50613-9117
US

IV. Provider business mailing address

9614 UNIVERSITY AVE APT 201H
CEDAR FALLS IA
50613-9117
US

V. Phone/Fax

Practice location:
  • Phone: 712-298-0033
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number680AJ1821
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: