Provider Demographics
NPI:1013770908
Name:MATIAS, JENISSE MARIE
Entity type:Individual
Prefix:MS
First Name:JENISSE
Middle Name:MARIE
Last Name:MATIAS
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:ALTURAS DE MAYAGUEZ
Mailing Address - Street 2:1900 CALLE LALIZA
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00682
Mailing Address - Country:US
Mailing Address - Phone:787-909-7534
Mailing Address - Fax:
Practice Address - Street 1:CALLE DR BASORA 55-N
Practice Address - Street 2:EDIFICIO MEDICO IV 201
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00682
Practice Address - Country:US
Practice Address - Phone:787-265-5583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-02
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7824103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling