Healthcare Provider Details

I. General information

NPI: 1578096632
Provider Name (Legal Business Name): JESSE JEFFREY MATTESON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JESSEE MATTESON DO

II. Dates (important events)

Enumeration Date: 04/06/2017
Last Update Date: 12/07/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 MEDICAL PARK BLVD
BRISTOL TN
37620-7343
US

IV. Provider business mailing address

200 CORPORATE BLVD
LAFAYETTE LA
70508-3870
US

V. Phone/Fax

Practice location:
  • Phone: 423-990-3012
  • Fax:
Mailing address:
  • Phone: 800-893-9698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number04681
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0102206958
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDO0000003617
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: