Provider Demographics
NPI:1851621296
Name:MATHEWS, JENNIFER ROSE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ROSE
Last Name:MATHEWS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9890 CLAYTON RD
Mailing Address - Street 2:SUITE 136
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63124-1685
Mailing Address - Country:US
Mailing Address - Phone:314-222-5872
Mailing Address - Fax:314-222-5873
Practice Address - Street 1:9890 CLAYTON RD
Practice Address - Street 2:SUITE 136
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63124-1685
Practice Address - Country:US
Practice Address - Phone:314-222-5872
Practice Address - Fax:314-222-5873
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-07
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009015463103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA3277Medicare UPIN