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General NPI Number Information
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NPI Number | 1164642617
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Entity Type | Individual
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Provider Name | JAYA MATHEW PH.D.
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Gender | Female
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Dates
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Enumeration Date | 04/26/2007
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Last Update Date | 06/18/2014
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Provider Practice Location Address
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Address Line | 1340 PRUDENTIAL DR # B
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City | DALLAS
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State | TX
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Zip | 75235-4115
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Country | US
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Telephone | 214-275-4667
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Fax |
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Provider Business Mailing Address
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Address Line | 21 N BUTLER ST APT 504
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City | MADISON
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State | WI
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Zip | 53703-4229
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Country | US
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Telephone | 214-755-7532
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 36584
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 3065-57
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License Number State | WI
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