Provider Demographics
NPI:1164599890
Name:MATRICIAN, JEFFREY S (LIC AC)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:S
Last Name:MATRICIAN
Suffix:
Gender:M
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 MOUNT AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-3992
Mailing Address - Country:US
Mailing Address - Phone:617-794-5787
Mailing Address - Fax:
Practice Address - Street 1:22 MOUNT AUBURN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-3992
Practice Address - Country:US
Practice Address - Phone:617-794-5787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216153171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist