Healthcare Provider Details

I. General information

NPI: 1679806608
Provider Name (Legal Business Name): JEREMY THOMPSON P.T,
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2009
Last Update Date: 09/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2780 W HORIZON RIDGE PKWY STE 40
HENDERSON NV
89052-3995
US

IV. Provider business mailing address

2780 W HORIZON RIDGE PKWY STE 40
HENDERSON NV
89052-3995
US

V. Phone/Fax

Practice location:
  • Phone: 702-564-4116
  • Fax: 702-932-2403
Mailing address:
  • Phone: 702-564-4116
  • Fax: 702-932-2403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number090170
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: