Provider Demographics
NPI:1245854496
Name:MATHEWS, JAIMIE LEIGH
Entity type:Individual
Prefix:
First Name:JAIMIE
Middle Name:LEIGH
Last Name:MATHEWS
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 1:3334 SSW LOOP 323 STE 114
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-9237
Mailing Address - Country:US
Mailing Address - Phone:903-343-6215
Mailing Address - Fax:
Practice Address - Street 1:3334 SSW LOOP 323 STE 114
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-9237
Practice Address - Country:US
Practice Address - Phone:903-343-6215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX203642106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist