Healthcare Provider Details

I. General information

NPI: 1689954893
Provider Name (Legal Business Name): KAREN M JENNINGS MATHIS PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2011
Last Update Date: 05/25/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 DUDLEY ST STE 560
PROVIDENCE RI
02905-3230
US

IV. Provider business mailing address

455 TOLLGATE RD PROFESSIONAL REVENUE CYCLE AND CREDENTIALING
WARWICK RI
02886-2759
US

V. Phone/Fax

Practice location:
  • Phone: 401-453-7955
  • Fax:
Mailing address:
  • Phone: 12-730-6414
  • Fax: 401-273-2919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN2267972
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN01971
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: