MEDICARE: DR. JACKSON GEORGE MATUELLA PT, DPT

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	225100000X	Physical Therapist	4212	NE

General Provider Information

NPI Number	:	1275101743
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACKSON GEORGE MATUELLA PT, DPT

Provider Business Mailing Address
First Line	:	625 N 144TH AVE STE 102
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68154-1935
Country	:	US
Telephone Number	:	402-934-8688
Fax Number	:

Provider Business Practice Location Address
First Line	:	625 N 144TH AVE STE 102
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68154-1935
Country	:	US
Telephone Number	:	402-934-8688
Fax Number	:

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

Provider Enumeration Date	:	06/11/2021
Last Update Date	:	06/11/2021

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Directions to “ DR. JACKSON GEORGE MATUELLA PT, DPT” Practice Location

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