Provider Demographics
NPI:1215506126
Name:MATERN, JESSICA E (COTA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:E
Last Name:MATERN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 N CENTER ST
Mailing Address - Street 2:
Mailing Address - City:FRACKVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17931-1205
Mailing Address - Country:US
Mailing Address - Phone:570-789-9643
Mailing Address - Fax:
Practice Address - Street 1:227 N CENTER ST
Practice Address - Street 2:
Practice Address - City:FRACKVILLE
Practice Address - State:PA
Practice Address - Zip Code:17931-1205
Practice Address - Country:US
Practice Address - Phone:570-789-9643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-24
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X
PA224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No171W00000XOther Service ProvidersContractorGroup - Single Specialty