Healthcare Provider Details

I. General information

NPI: 1023293669
Provider Name (Legal Business Name): JACQUELINE THOMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2008
Last Update Date: 01/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8060 KNUE RD STE 110
INDIANAPOLIS IN
46250-1938
US

IV. Provider business mailing address

3281 ASHLEY LN
INDIANAPOLIS IN
46224-2226
US

V. Phone/Fax

Practice location:
  • Phone: 317-842-7435
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number71-01-93-3229
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: