Provider Demographics
NPI:1801298922
Name:MATHIS, JANINE
Entity type:Individual
Prefix:
First Name:JANINE
Middle Name:
Last Name:MATHIS
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 1:1218 E COMPTON BLVD
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90221-3310
Mailing Address - Country:US
Mailing Address - Phone:310-608-1505
Mailing Address - Fax:310-608-1406
Practice Address - Street 1:1218 E COMPTON BLVD
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90221-3310
Practice Address - Country:US
Practice Address - Phone:310-608-1505
Practice Address - Fax:310-608-1406
Is Sole Proprietor?:No
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA7860612101YA0400X
CAM1303261336101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health