Provider Demographics
NPI:1689177909
Name:MATISOFF, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MATISOFF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2518 THAYNE DR
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:TX
Mailing Address - Zip Code:75409-0197
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:804 PECAN GROVE RD E
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75090-1767
Practice Address - Country:US
Practice Address - Phone:903-893-7768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX77601101YP2500X, 101Y00000X, 101YM0800X
TX76701101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX77601OtherJESSICA MATISOFF