Provider Demographics
NPI:1669957080
Name:MATACCHIERA, JACQUELINE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MATACCHIERA
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 1:40 GATES PL
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-3217
Mailing Address - Country:US
Mailing Address - Phone:201-724-1190
Mailing Address - Fax:
Practice Address - Street 1:420 BOULEVARD STE 101
Practice Address - Street 2:
Practice Address - City:MOUNTAIN LAKES
Practice Address - State:NJ
Practice Address - Zip Code:07046-1733
Practice Address - Country:US
Practice Address - Phone:973-988-0035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00279900101YA0400X
NJ37PC00585900101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherDO SERVE MEDICAID CLIENTS AS OF YET