Provider Demographics
NPI:1457008872
Name:MATHEW, JENCYMOL (APRN, PMHNP)
Entity type:Individual
Prefix:
First Name:JENCYMOL
Middle Name:
Last Name:MATHEW
Suffix:
Gender:F
Credentials:APRN, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8136 CENTRALIA CT STE 101
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34788-3757
Mailing Address - Country:US
Mailing Address - Phone:800-614-4124
Mailing Address - Fax:
Practice Address - Street 1:8136 CENTRALIA CT STE 101
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34788-3757
Practice Address - Country:US
Practice Address - Phone:800-614-4124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-05
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11018479363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health