Healthcare Provider Details

I. General information

NPI: 1013492404
Provider Name (Legal Business Name): JACQUIE LYNN MATHAI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2018
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 CAMINO GARDENS BLVD
BOCA RATON FL
33432-5816
US

IV. Provider business mailing address

8440 NW 24TH ST
SUNRISE FL
33322-3318
US

V. Phone/Fax

Practice location:
  • Phone: 954-456-4777
  • Fax:
Mailing address:
  • Phone: 954-604-2203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9111498
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: