Healthcare Provider Details

I. General information

NPI: 1043294796
Provider Name (Legal Business Name): JACQUELINE SUE THOMPSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1204 BROWN STREET
WASHINGTON NC
27889
US

IV. Provider business mailing address

6455 RIVER ROAD
WASHINGTON NC
27889
US

V. Phone/Fax

Practice location:
  • Phone: 252-946-6544
  • Fax: 252-975-6540
Mailing address:
  • Phone: 252-946-6544
  • Fax: 252-975-6540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number9601142
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: