Provider Demographics
NPI:1689740623
Name:MATEJKA, MARILYN A (LADC)
Entity Type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:A
Last Name:MATEJKA
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 W ASHLEY ST
Mailing Address - Street 2:P.O. BOX 143
Mailing Address - City:JACKSON
Mailing Address - State:MN
Mailing Address - Zip Code:56143-1568
Mailing Address - Country:US
Mailing Address - Phone:507-847-3148
Mailing Address - Fax:507-847-3206
Practice Address - Street 1:308 W ASHLEY ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MN
Practice Address - Zip Code:56143-1568
Practice Address - Country:US
Practice Address - Phone:507-847-3148
Practice Address - Fax:507-847-3206
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300459101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)