Provider Demographics
NPI:1003566993
Name:MATHIEU, JEAN EDWARD JR
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:EDWARD
Last Name:MATHIEU
Suffix:JR
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 1:2214 N 45TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34946-1536
Mailing Address - Country:US
Mailing Address - Phone:901-364-1278
Mailing Address - Fax:
Practice Address - Street 1:2214 N 45TH ST
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34946-1536
Practice Address - Country:US
Practice Address - Phone:901-364-1278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-84851106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103091200Medicaid