=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871806430
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNA MARIE THOMPSON MSW, LSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2010
-----------------------------------------------------
Last Update Date | 04/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 408 E NORTH ST 4166 SIERRA CIRCLE
-----------------------------------------------------
City | MEDINA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44256-1952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 567-277-3679
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 408 E NORTH ST 4166 SIERRA CIRCLE
-----------------------------------------------------
City | MEDINA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44256-1952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 567-277-3679
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | S.1000179
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------