Provider Demographics
NPI:1669637807
Name:MATTSON, JESSICA KIERSTEN (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:KIERSTEN
Last Name:MATTSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:KIERSTEN
Other - Last Name:REY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1329 LUSITANA ST STE 807
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2435
Mailing Address - Country:US
Mailing Address - Phone:603-321-1099
Mailing Address - Fax:
Practice Address - Street 1:1329 LUSITANA ST STE 807
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2435
Practice Address - Country:US
Practice Address - Phone:603-321-1099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-28
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH107724Medicaid