Provider Demographics
NPI:1346793056
Name:MATHEY MAC LELLAN, JENNIFER S
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:MATHEY MAC LELLAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 PARKMOOR AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2407
Mailing Address - Country:US
Mailing Address - Phone:408-282-0402
Mailing Address - Fax:
Practice Address - Street 1:1603A S MAIN ST
Practice Address - Street 2:
Practice Address - City:MILPITAS
Practice Address - State:CA
Practice Address - Zip Code:95035-6261
Practice Address - Country:US
Practice Address - Phone:408-913-5019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-28
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 106H00000X
CA146685106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst