Provider Demographics
NPI:1699112482
Name:THOMASON, BENTLEY JESSICA MAE (MD)
Entity type:Individual
Prefix:DR
First Name:BENTLEY
Middle Name:JESSICA MAE
Last Name:THOMASON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JESSICA
Other - Middle Name:MAE
Other - Last Name:BENTLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3 NEENAH CTR
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3070
Mailing Address - Country:US
Mailing Address - Phone:715-524-2161
Mailing Address - Fax:715-524-8164
Practice Address - Street 1:100 COUNTY ROAD B
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-7072
Practice Address - Country:US
Practice Address - Phone:715-524-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA133000207Q00000X
WI76345207V00000X, 207Q00000X
IDM-13560207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology