Healthcare Provider Details

I. General information

NPI: 1265673107
Provider Name (Legal Business Name): JARED ROBERT MATTESON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2009
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 WELLS ST
WESTERLY RI
02891-2922
US

IV. Provider business mailing address

690 CANTON ST SUITE 325
WESTWOOD MA
02090-2321
US

V. Phone/Fax

Practice location:
  • Phone: 203-688-0715
  • Fax:
Mailing address:
  • Phone: 781-407-7713
  • Fax: 781-407-0998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number41284
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN00591
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: