Provider Demographics
NPI:1417355496
Name:MATA, JESSIEKA (M A, MS, PPS)
Entity Type:Individual
Prefix:
First Name:JESSIEKA
Middle Name:
Last Name:MATA
Suffix:
Gender:F
Credentials:M A, MS, PPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5284 ALDOLFO RD.
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012
Mailing Address - Country:US
Mailing Address - Phone:805-289-0128
Mailing Address - Fax:805-289-0130
Practice Address - Street 1:5284 ALDOLFO RD.
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012
Practice Address - Country:US
Practice Address - Phone:805-289-0128
Practice Address - Fax:805-289-0130
Is Sole Proprietor?:No
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA56CCOtherASPIRA