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NPI Code Detail

MEDICARE: JESSICA RENE MATUS MA, BCBA, LBA

MEDICARE: JESSICA RENE MATUS MA, BCBA, LBA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103K00000XBehavior AnalystBEH-000385AZ

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11-18-30592OTHERBCBA CERTIFICATE

General Provider Information

NPI Number : 1134695034
Entity Type Code : Individual
Provider Name (Legal Business Name) : JESSICA RENE MATUS MA, BCBA, LBA
Provider Business Mailing Address
First Line : 3500 DEPAUW BLVD STE 3070
Second Line :
City : INDIANAPOLIS
State : IN
Zip : 46268-6135
Country : US
Telephone Number : 855-324-0885
Fax Number : 317-520-8200
Provider Business Practice Location Address
First Line : 5859 W TALAVI BLVD STE 180
Second Line :
City : GLENDALE
State : AZ
Zip : 85306-1873
Country : US
Telephone Number : 602-560-2836
Fax Number : 317-520-8200
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/17/2018
Last Update Date : 08/04/2020

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