Provider Demographics
NPI:1629785266
Name:MATOS, JONATHAN C (MA COUNSELING)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:C
Last Name:MATOS
Suffix:
Gender:M
Credentials:MA COUNSELING
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6443 BURLWOOD RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-5603
Mailing Address - Country:US
Mailing Address - Phone:980-275-0143
Mailing Address - Fax:
Practice Address - Street 1:3646 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-6064
Practice Address - Country:US
Practice Address - Phone:704-910-5810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA18188101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional