Provider Demographics
NPI:1568747822
Name:MATHENIA, JESSICA LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:MATHENIA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:REUTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:5000 ESTATE ENIGHED
Mailing Address - Street 2:PMB 214
Mailing Address - City:ST JOHN
Mailing Address - State:VI
Mailing Address - Zip Code:00830
Mailing Address - Country:UM
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6500 RED HOOK PLAZA
Practice Address - Street 2:SUITE 205
Practice Address - City:ST THOMAS
Practice Address - State:VI
Practice Address - Zip Code:00802
Practice Address - Country:UM
Practice Address - Phone:340-775-2303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004185363A00000X, 363AM0700X
VI106207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical