Provider Demographics
NPI:1205196268
Name:MATIYOSUS, JENNIFER ANNNE
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANNNE
Last Name:MATIYOSUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:283 BIRCHBARK DR
Mailing Address - Street 2:
Mailing Address - City:HANSON
Mailing Address - State:MA
Mailing Address - Zip Code:02341-2103
Mailing Address - Country:US
Mailing Address - Phone:339-788-7873
Mailing Address - Fax:
Practice Address - Street 1:283 BIRCHBARK DR
Practice Address - Street 2:
Practice Address - City:HANSON
Practice Address - State:MA
Practice Address - Zip Code:02341-2103
Practice Address - Country:US
Practice Address - Phone:339-788-7873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-24
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)