Provider Demographics
NPI:1417395484
Name:MATOVICH, JENNIFER (PSYD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MATOVICH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14498 SCOTTS LN
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:VA
Mailing Address - Zip Code:23830-9539
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13301 MIDLOTHIAN TPKE STE D
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-4205
Practice Address - Country:US
Practice Address - Phone:804-239-7688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-12
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810004304103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical