Provider Demographics
NPI:1275040586
Name:MATTERA, JENNA ANTONETTE (DPT)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:ANTONETTE
Last Name:MATTERA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-2318
Mailing Address - Country:US
Mailing Address - Phone:781-521-3336
Mailing Address - Fax:
Practice Address - Street 1:334 NEWBURY ST
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:781-521-3336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA22483225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist