MEDICARE: DR. JAYA MATHEW PH.D.

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
1	103T00000X	Psychologist	36584	TX
2	103T00000X	Psychologist	3065-57	WI

General Provider Information

NPI Number	:	1164642617
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAYA MATHEW PH.D.

Provider Business Mailing Address
First Line	:	21 N BUTLER ST APT 504
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53703-4229
Country	:	US
Telephone Number	:	214-755-7532
Fax Number	:

Provider Business Practice Location Address
First Line	:	1340 PRUDENTIAL DR # B
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75235-4115
Country	:	US
Telephone Number	:	214-275-4667
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2007
Last Update Date	:	06/18/2014

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Directions to “ DR. JAYA MATHEW PH.D.” Practice Location

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