Provider Demographics
NPI:1578096632
Name:MATTESON, JESSE JEFFREY (DO)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:JEFFREY
Last Name:MATTESON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:JESSEE
Other - Middle Name:
Other - Last Name:MATTESON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:208 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7343
Practice Address - Country:US
Practice Address - Phone:423-990-3012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-06
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY04681207P00000X
390200000X
VA0102206958207P00000X
TNDO0000003617207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program