1093164402 NPI number — MS. JESSICA LYNN MATIS DNP, APRN, ACNP-AG

Table of content: MS. JESSICA LYNN MATIS DNP, APRN, ACNP-AG (NPI 1093164402)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093164402 NPI number — MS. JESSICA LYNN MATIS DNP, APRN, ACNP-AG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATIS
Provider First Name:
JESSICA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
DNP, APRN, ACNP-AG
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093164402
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2101 MILL RD APT 113
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22314-5318
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-450-1334
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
GOODWIN HOUSE
Provider Second Line Business Practice Location Address:
3440 S. JEFFERSON STREET
Provider Business Practice Location Address City Name:
BAILEYS CROSSROADS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22041-2204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-820-1488
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/07/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LG0600X , with the licence number:  3010039 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2100X , with the licence number: 3010039 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 201391850 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 50112260 . This is a "PASSPORT - NNIKY" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 0000001021475 . This is a "ANTHEM - NNIKY" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 215034 . This is a "SIHO - NNIKY" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 7100415610 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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