Provider Demographics
NPI:1790304723
Name:MATEO, JOLYN VIRGINIA
Entity Type:Individual
Prefix:
First Name:JOLYN
Middle Name:VIRGINIA
Last Name:MATEO
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:PO BOX 241464
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99524-1464
Mailing Address - Country:US
Mailing Address - Phone:907-274-7391
Mailing Address - Fax:907-274-7392
Practice Address - Street 1:1058 W 27TH AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-2424
Practice Address - Country:US
Practice Address - Phone:907-274-7391
Practice Address - Fax:907-274-7392
Is Sole Proprietor?:No
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider