Provider Demographics
NPI:1093164402
Name:MATIS, JESSICA LYNN (DNP, APRN, ACNP-AG)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:LYNN
Last Name:MATIS
Suffix:
Gender:F
Credentials:DNP, APRN, ACNP-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 MILL RD APT 113
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-5318
Mailing Address - Country:US
Mailing Address - Phone:573-450-1334
Mailing Address - Fax:
Practice Address - Street 1:GOODWIN HOUSE
Practice Address - Street 2:3440 S. JEFFERSON STREET
Practice Address - City:BAILEYS CROSSROADS
Practice Address - State:VA
Practice Address - Zip Code:22041-2204
Practice Address - Country:US
Practice Address - Phone:703-820-1488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3010039363LG0600X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201391850Medicaid
KY50112260OtherPASSPORT - NNIKY
KY0000001021475OtherANTHEM - NNIKY
LA215034OtherSIHO - NNIKY
KY7100415610Medicaid
KYK170480Medicare PIN