Provider Demographics
NPI:1730754326
Name:THOMPSON, JELISIA JEMAE
Entity type:Individual
Prefix:
First Name:JELISIA
Middle Name:JEMAE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 BROCKDEN DR
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-3275
Mailing Address - Country:US
Mailing Address - Phone:952-393-7755
Mailing Address - Fax:
Practice Address - Street 1:102 BROTHERS BLVD
Practice Address - Street 2:
Practice Address - City:RED OAK
Practice Address - State:TX
Practice Address - Zip Code:75154-6152
Practice Address - Country:US
Practice Address - Phone:469-673-8867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-21-49405103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst