Provider Demographics
NPI:1699218529
Name:MATA, JESSE ENRIQUE
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:ENRIQUE
Last Name:MATA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7585 NW MOUNTAIN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-9751
Mailing Address - Country:US
Mailing Address - Phone:541-231-1827
Mailing Address - Fax:
Practice Address - Street 1:7585 NW MOUNTAIN VIEW DR
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-9751
Practice Address - Country:US
Practice Address - Phone:541-231-1872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-25
Last Update Date:2016-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other