Provider Demographics
NPI:1154626950
Name:MATTACHIONE, JACK ANTHONY SR
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:ANTHONY
Last Name:MATTACHIONE
Suffix:SR
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 1:4610 SW 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914-1704
Mailing Address - Country:US
Mailing Address - Phone:239-313-9472
Mailing Address - Fax:
Practice Address - Street 1:2180 MARAVILLA LN
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-7221
Practice Address - Country:US
Practice Address - Phone:239-322-2970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health