Basic Information
Provider Information | |||||||||
NPI: | 1790822658 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | THOMPSON-JENSSEN | ||||||||
FirstName: | RAYNA | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPCC-S | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JENSSEN | ||||||||
OtherFirstName: | RAYNA | ||||||||
OtherMiddleName: | J | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 651 SOUTH LIMESTONE STREET | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | OH | ||||||||
PostalCode: | 45505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9373241111 | ||||||||
FaxNumber: | 9375254542 | ||||||||
Practice Location | |||||||||
Address1: | 651 S LIMESTONE ST | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | OH | ||||||||
PostalCode: | 455051965 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9373241111 | ||||||||
FaxNumber: | 9373287257 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/31/2007 | ||||||||
LastUpdateDate: | 06/03/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/03/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | E.0002160-SUPV | OH | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.