Provider Demographics
NPI:1053447979
Name:THOMPSON, JACQUELINE A (LPN)
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:A
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 HEATHECOTE ROAD
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003
Mailing Address - Country:US
Mailing Address - Phone:515-616-5941
Mailing Address - Fax:718-358-7473
Practice Address - Street 1:184 HEATHECOTE ROAD
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003
Practice Address - Country:US
Practice Address - Phone:515-616-5941
Practice Address - Fax:718-358-7473
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00164089164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00164089OtherNY STATE NURSING LICENSE
NYPBHMedicaid
NY01945711Medicaid