Healthcare Provider Details

I. General information

NPI: 1205468048
Provider Name (Legal Business Name): JUSTINE THOMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2020
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1280 E CAMPUS DR
MOUNT PLEASANT MI
48859-3803
US

IV. Provider business mailing address

1280 E CAMPUS DR
MOUNT PLEASANT MI
48859-2033
US

V. Phone/Fax

Practice location:
  • Phone: 989-205-3807
  • Fax:
Mailing address:
  • Phone: 989-205-3807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601010150
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: