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General NPI Number Information
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NPI Number | 1740987304
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Entity Type | Individual
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Provider Name | JACOB THOMPSON
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Gender | Male
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Dates
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Enumeration Date | 02/13/2023
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Last Update Date | 02/13/2023
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Provider Practice Location Address
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Address Line | 4020 E NEW YORK ST
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City | AURORA
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State | IL
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Zip | 60504-4416
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Country | US
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Telephone | 331-301-5590
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Fax |
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Provider Business Mailing Address
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Address Line | 704 N 12TH ST APT 2
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City | DEKALB
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State | IL
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Zip | 60115-4345
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Country | US
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Telephone | 608-513-8969
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Fax |
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 070.026610
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License Number State | IL
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