Provider Demographics
NPI:1437928553
Name:MATTHEWS, JAMIE SHANELL
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:SHANELL
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:SHANELL
Other - Last Name:KEARSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6106 PORTICO DR APT 1123
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4173
Mailing Address - Country:US
Mailing Address - Phone:803-586-4040
Mailing Address - Fax:
Practice Address - Street 1:6106 PORTICO DR APT 1123
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4173
Practice Address - Country:US
Practice Address - Phone:803-586-4040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-29
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional