Healthcare Provider Details

I. General information

NPI: 1861520280
Provider Name (Legal Business Name): JACLYN RAE THOMPSON RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4325 GRAND AVE
DULUTH MN
55807-2730
US

IV. Provider business mailing address

2222 E 5TH ST
SUPERIOR WI
54880-3709
US

V. Phone/Fax

Practice location:
  • Phone: 218-628-7035
  • Fax: 218-624-6594
Mailing address:
  • Phone: 715-392-1955
  • Fax: 715-392-1935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH7723
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: