Provider Demographics
NPI:1184278327
Name:MATHEWS, JENNIFER R (BA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:MATHEWS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:SIMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:14949 62ND ST N
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6102
Mailing Address - Country:US
Mailing Address - Phone:651-430-6520
Mailing Address - Fax:651-428-6128
Practice Address - Street 1:14949 62ND ST N
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6102
Practice Address - Country:US
Practice Address - Phone:651-430-6520
Practice Address - Fax:651-428-6128
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health