Healthcare Provider Details

I. General information

NPI: 1174931463
Provider Name (Legal Business Name): JENNIFER BERRY MATTHESEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER ANNE BERRY MD

II. Dates (important events)

Enumeration Date: 07/30/2014
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 TOWN PLAZA AVE STE 410
PONTE VEDRA FL
32081-5177
US

IV. Provider business mailing address

112 BRISTOL PL
PONTE VEDRA BEACH FL
32082-1523
US

V. Phone/Fax

Practice location:
  • Phone: 904-285-7202
  • Fax: 904-285-3931
Mailing address:
  • Phone: 904-395-3714
  • Fax: 904-285-3931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number53345
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number277360
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberME132012
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA83217
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: