Provider Demographics
NPI:1326218413
Name:MATTESON, JACK E (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:E
Last Name:MATTESON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1026 NORTHEAST DR
Mailing Address - Street 2:STE E
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-2517
Mailing Address - Country:US
Mailing Address - Phone:573-635-3850
Mailing Address - Fax:573-635-1558
Practice Address - Street 1:1026 NORTHEAST DR
Practice Address - Street 2:STE E
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-2517
Practice Address - Country:US
Practice Address - Phone:573-635-3850
Practice Address - Fax:573-635-1558
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20070378592084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAB68088Medicare UPIN