Provider Demographics
NPI:1881000594
Name:MATSO, JENNA B
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:B
Last Name:MATSO
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 1:1917 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-7041
Mailing Address - Country:US
Mailing Address - Phone:419-202-7649
Mailing Address - Fax:
Practice Address - Street 1:4580 LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:VERMILION
Practice Address - State:OH
Practice Address - Zip Code:44089-3285
Practice Address - Country:US
Practice Address - Phone:440-967-2018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03234041183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist