Healthcare Provider Details

I. General information

NPI: 1396184131
Provider Name (Legal Business Name): MICHAEL KENNETH THOMPSON MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2013
Last Update Date: 06/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 E MICHIGAN AVE
JACKSON MI
49202-3700
US

IV. Provider business mailing address

2301 E MICHIGAN AVE
JACKSON MI
49202-3700
US

V. Phone/Fax

Practice location:
  • Phone: 517-783-3434
  • Fax: 517-784-7546
Mailing address:
  • Phone: 517-783-3434
  • Fax: 517-784-7546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301007608
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: