Basic Information
Provider Information
NPI: 1003142647
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MATTHEWS
FirstName: JESSICA
MiddleName: N
NamePrefix: MS.
NameSuffix:  
Credential: CNA
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 751 CEDAR CREEK RD NW
Address2:  
City: CARTERSVILLE
State: GA
PostalCode: 301214409
CountryCode: US
TelephoneNumber: 7706554426
FaxNumber:  
Practice Location
Address1: 751 CEDAR CREEK RD NW
Address2:  
City: CARTERSVILLE
State: GA
PostalCode: 301214409
CountryCode: US
TelephoneNumber: 7706554426
FaxNumber:  
Other Information
ProviderEnumerationDate: 11/01/2009
LastUpdateDate: 11/01/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
376K00000XCN0028865250GAY Nursing Service Related ProvidersNurse's Aide 

No ID Information.


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