Provider Demographics
NPI:1376527861
Name:MATHESON, JOLIE KIM BRENHOFER (MS)
Entity Type:Individual
Prefix:MS
First Name:JOLIE KIM
Middle Name:BRENHOFER
Last Name:MATHESON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:JOLIE
Other - Middle Name:K
Other - Last Name:MATHESON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CGC
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:774-442-5695
Practice Address - Fax:508-334-8496
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAGC077170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS