Provider Demographics
NPI:1831313865
Name:MATTERSON, JENNIE (BA)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:MATTERSON
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 HAZEL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19810-1311
Mailing Address - Country:US
Mailing Address - Phone:302-345-0487
Mailing Address - Fax:
Practice Address - Street 1:212 BLUE BALL AVE
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-5222
Practice Address - Country:US
Practice Address - Phone:410-620-6077
Practice Address - Fax:410-620-6081
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD101YA0400XMedicaid