Healthcare Provider Details

I. General information

NPI: 1245848258
Provider Name (Legal Business Name): JENNY L MATTHEWS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2020
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W ANDERSON LN STE C100
AUSTIN TX
78752-1119
US

IV. Provider business mailing address

111 W ANDERSON LN STE C100
AUSTIN TX
78752-1119
US

V. Phone/Fax

Practice location:
  • Phone: 512-451-0961
  • Fax: 888-253-7178
Mailing address:
  • Phone: 512-451-0961
  • Fax: 888-253-7178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number32597
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: