Provider Demographics
NPI:1588905640
Name:THOMAS, JEROME LOUIE
Entity type:Individual
Prefix:MR
First Name:JEROME
Middle Name:LOUIE
Last Name:THOMAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 W UNIVERSITY DR STE 101
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-5856
Mailing Address - Country:US
Mailing Address - Phone:602-538-9084
Mailing Address - Fax:
Practice Address - Street 1:86 W UNIVERSITY DR STE 101
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-5856
Practice Address - Country:US
Practice Address - Phone:602-538-9084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-13
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-00485-P173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ17OtherLICENSED MASSAGE THERAPIST