Healthcare Provider Details

I. General information

NPI: 1457110777
Provider Name (Legal Business Name): MATTHEW DAVID JERNIGAN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2024
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 E HUNTLAND DR STE 320
AUSTIN TX
78752-3741
US

IV. Provider business mailing address

PO BOX 301183
AUSTIN TX
78703-0020
US

V. Phone/Fax

Practice location:
  • Phone: 512-201-4501
  • Fax:
Mailing address:
  • Phone: 910-818-1397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number105457
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: