Provider Demographics
NPI:1972712438
Name:MATTIKO, JENNIFER REBECCA (MA, CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:JENNIFER
Middle Name:REBECCA
Last Name:MATTIKO
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 BRENTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:CAMP HILL
Mailing Address - State:PA
Mailing Address - Zip Code:17011-2506
Mailing Address - Country:US
Mailing Address - Phone:717-730-0511
Mailing Address - Fax:717-730-0511
Practice Address - Street 1:34 BRENTWOOD RD
Practice Address - Street 2:
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011-2506
Practice Address - Country:US
Practice Address - Phone:717-730-0511
Practice Address - Fax:717-730-0511
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL006062L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017858060004Medicaid