Provider Demographics
NPI:1306859103
Name:THOMPSON, JEAN G (BCO)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:G
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:BCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4118 MCCULLOUGH AVE
Mailing Address - Street 2:SUITE 16
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-1979
Mailing Address - Country:US
Mailing Address - Phone:210-223-3754
Mailing Address - Fax:210-223-1949
Practice Address - Street 1:4118 MCCULLOUGH AVE
Practice Address - Street 2:SUITE 16
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-1979
Practice Address - Country:US
Practice Address - Phone:210-223-3754
Practice Address - Fax:210-223-1949
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX513442OtherBLUECROSS BLUESHIELD
TX0441390001Medicare ID - Type Unspecified