Provider Demographics
NPI:1326589631
Name:MATA, JESSELEE REYES (BSPT)
Entity Type:Individual
Prefix:
First Name:JESSELEE
Middle Name:REYES
Last Name:MATA
Suffix:
Gender:M
Credentials:BSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 COURT DR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-1478
Mailing Address - Country:US
Mailing Address - Phone:704-824-7800
Mailing Address - Fax:704-824-2822
Practice Address - Street 1:2 CADDO CROSSING DR
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:AR
Practice Address - Zip Code:71943-8882
Practice Address - Country:US
Practice Address - Phone:870-356-4954
Practice Address - Fax:870-356-4956
Is Sole Proprietor?:No
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4267225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist