Provider Demographics
NPI:1215540026
Name:MATLOCK, JENNA M (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:M
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:M
Other - Last Name:PROVANCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7100 W CENTER RD
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68106-2714
Mailing Address - Country:US
Mailing Address - Phone:402-506-9000
Mailing Address - Fax:402-506-9093
Practice Address - Street 1:7100 W CENTER RD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68106-2714
Practice Address - Country:US
Practice Address - Phone:402-506-9000
Practice Address - Fax:402-506-9093
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 363AM0700X
NE2545363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical