Provider Demographics
NPI:1184791956
Name:MATTSON, FENJA (AUD)
Entity type:Individual
Prefix:DR
First Name:FENJA
Middle Name:
Last Name:MATTSON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 N DAVIS ST STE 101
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-6808
Mailing Address - Country:US
Mailing Address - Phone:904-355-3403
Mailing Address - Fax:904-355-4149
Practice Address - Street 1:1010 N DAVIS ST STE 101
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6808
Practice Address - Country:US
Practice Address - Phone:904-355-3403
Practice Address - Fax:904-355-4149
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY 1153231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6003877-00Medicaid
FL6003877-00Medicaid