Healthcare Provider Details

I. General information

NPI: 1366002701
Provider Name (Legal Business Name): JENNIFER MATA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32565 GOLDEN LANTERN SUITE B 180
DANA POINT CA
92629
US

IV. Provider business mailing address

32565 GOLDEN LANTERN SUITE B 180
DANA POINT CA
92629
US

V. Phone/Fax

Practice location:
  • Phone: 714-552-1317
  • Fax: 714-782-5611
Mailing address:
  • Phone: 714-552-1317
  • Fax: 714-782-5611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: