Provider Demographics
NPI:1326314410
Name:MATTHEWS, JAIRUS-JOAQUIN R
Entity Type:Individual
Prefix:MR
First Name:JAIRUS-JOAQUIN
Middle Name:R
Last Name:MATTHEWS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2927 SMITH RIDGE TRCE
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30071-2643
Mailing Address - Country:US
Mailing Address - Phone:678-458-0607
Mailing Address - Fax:
Practice Address - Street 1:2927 SMITH RIDGE TRCE
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-2643
Practice Address - Country:US
Practice Address - Phone:678-458-0607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006746235Z00000X
CA16975235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist