MEDICARE: JACK E MATTESON M.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	2084P0800X	Psychiatry Physician	2007037859	MO
2	2084P0804X	Child & Adolescent Psychiatry Physician	2007037859	MO

General Provider Information

NPI Number	:	1326218413
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK E MATTESON M.D.

Provider Business Mailing Address
First Line	:	1026 NORTHEAST DR
Second Line	:	STE E
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65109-2517
Country	:	US
Telephone Number	:	573-635-3850
Fax Number	:	573-635-1558

Provider Business Practice Location Address
First Line	:	1026 NORTHEAST DR
Second Line	:	STE E
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65109-2517
Country	:	US
Telephone Number	:	573-635-3850
Fax Number	:	573-635-1558

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

Provider Enumeration Date	:	03/05/2008
Last Update Date	:	12/15/2010

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