Healthcare Provider Details

I. General information

NPI: 1578819835
Provider Name (Legal Business Name): COURTNEY THOMPSON O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2012
Last Update Date: 03/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W WOODROW WILSON AVE SUITE 3110
JACKSON MS
39213-7681
US

IV. Provider business mailing address

PO BOX 2355
RIDGELAND MS
39158-2355
US

V. Phone/Fax

Practice location:
  • Phone: 601-366-9020
  • Fax: 601-321-3979
Mailing address:
  • Phone: 769-208-8930
  • Fax: 769-208-8831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number867
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: