Provider Demographics
NPI:1508927526
Name:MOUNT MATNEY, JESSICA MICHELE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MICHELE
Last Name:MOUNT MATNEY
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 CLAUDINE ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-5602
Mailing Address - Country:US
Mailing Address - Phone:505-453-1714
Mailing Address - Fax:
Practice Address - Street 1:230 TRUMAN ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1333
Practice Address - Country:US
Practice Address - Phone:505-268-9506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3723235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM88527522Medicaid