Provider Demographics
NPI:1922387521
Name:JAEN, MATTHEW ANTONIO (RN)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:ANTONIO
Last Name:JAEN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 ODELL ST
Mailing Address - Street 2:APT. 5D
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-7053
Mailing Address - Country:US
Mailing Address - Phone:917-767-7950
Mailing Address - Fax:
Practice Address - Street 1:1575 ODELL ST
Practice Address - Street 2:APT. 5D
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-7053
Practice Address - Country:US
Practice Address - Phone:917-767-7950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-12
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY640967-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse