Provider Demographics
NPI:1679632616
Name:MATHISEN, JANE M (MD)
Entity Type:Individual
Prefix:DR
First Name:JANE
Middle Name:M
Last Name:MATHISEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:445 ROCKLAND RD
Mailing Address - Street 2:
Mailing Address - City:MERION STATION
Mailing Address - State:PA
Mailing Address - Zip Code:19066-1354
Mailing Address - Country:US
Mailing Address - Phone:610-667-6806
Mailing Address - Fax:
Practice Address - Street 1:1 BALA AVE
Practice Address - Street 2:SUITE 118
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-3207
Practice Address - Country:US
Practice Address - Phone:610-667-2557
Practice Address - Fax:610-667-2445
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD036291E2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
E52507Medicare UPIN