Provider Demographics
NPI:1073884938
Name:MATASICK, JENNIFER KANE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:KANE
Last Name:MATASICK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 17TH ST SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-1641
Mailing Address - Country:US
Mailing Address - Phone:978-430-5307
Mailing Address - Fax:
Practice Address - Street 1:1555 CONNECTICUT AVE NW
Practice Address - Street 2:SUITE 500
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20036-1111
Practice Address - Country:US
Practice Address - Phone:202-234-0903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-24
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPSY1000755103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist