Provider Demographics
NPI:1386917029
Name:THOMSON, JACEY LANE (DPT)
Entity type:Individual
Prefix:
First Name:JACEY
Middle Name:LANE
Last Name:THOMSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JACEY
Other - Middle Name:LANE
Other - Last Name:HENDRICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:2488 E 81ST ST STE 290
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-4265
Mailing Address - Country:US
Mailing Address - Phone:918-494-9341
Mailing Address - Fax:918-494-9355
Practice Address - Street 1:1071 W BLUE STARR DR STE 105
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-2869
Practice Address - Country:US
Practice Address - Phone:918-283-2992
Practice Address - Fax:918-283-2952
Is Sole Proprietor?:No
Enumeration Date:2012-02-10
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4367225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200423090AMedicaid