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General NPI Number Information
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NPI Number | 1831664424
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Entity Type | Individual
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Provider Name | JESSICA LEIGH MATTIACE
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Gender | Female
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Dates
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Enumeration Date | 10/10/2018
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Last Update Date | 10/10/2018
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Provider Practice Location Address
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Address Line | 605 HERZEL AVE
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City | NORTHFIELD
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State | NJ
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Zip | 08225-1237
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Country | US
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Telephone | 609-425-9182
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Fax |
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Provider Business Mailing Address
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Address Line | 605 HERZEL AVE
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City | NORTHFIELD
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State | NJ
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Zip | 08225-1237
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Country | US
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Telephone | 609-425-9182
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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 | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 12124313
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License Number State | NJ
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