Provider Demographics
NPI:1831738079
Name:MATA, JENNIFER JEAN (CNP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:JEAN
Last Name:MATA
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 MILDRED AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPERANCE
Mailing Address - State:MI
Mailing Address - Zip Code:48182-9203
Mailing Address - Country:US
Mailing Address - Phone:734-244-2353
Mailing Address - Fax:
Practice Address - Street 1:1414 STEWART RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-9228
Practice Address - Country:US
Practice Address - Phone:734-242-8880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-06
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704305266163WG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0600XNursing Service ProvidersRegistered NurseGerontology