Provider Demographics
NPI:1669514253
Name:MATTERN, JILL MARIE
Entity type:Individual
Prefix:MS
First Name:JILL
Middle Name:MARIE
Last Name:MATTERN
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 1:201 BRUSH ST
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-3424
Mailing Address - Country:US
Mailing Address - Phone:707-462-6290
Mailing Address - Fax:707-468-6427
Practice Address - Street 1:201 BRUSH ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-3424
Practice Address - Country:US
Practice Address - Phone:707-462-6290
Practice Address - Fax:707-468-6427
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CAA78277207V00000X
NY242578-1207V00000X
CA14753101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology