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General NPI Number Information
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NPI Number | 1699112482
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Entity Type | Individual
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Provider Name | BENTLEY JESSICA MAE THOMASON MD
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Gender | Female
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Dates
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Enumeration Date | 06/03/2013
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Last Update Date | 01/04/2022
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Provider Practice Location Address
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Address Line | 100 COUNTY ROAD B
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City | SHAWANO
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State | WI
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Zip | 54166-7072
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Country | US
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Telephone | 715-524-2161
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Fax |
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Provider Business Mailing Address
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Address Line | 3 NEENAH CTR
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City | NEENAH
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State | WI
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Zip | 54956-3070
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Country | US
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Telephone | 715-524-2161
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Fax | 715-524-8164
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | A133000
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | 76345
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License Number State | WI
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 76345
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License Number State | WI
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Taxonomy #4
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | M-13560
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License Number State | ID
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