Provider Demographics
NPI:1689447716
Name:JONATHAN MATTICE FAMILY THERAPY CORPORATION
Entity type:Organization
Organization Name:JONATHAN MATTICE FAMILY THERAPY CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MATTICE
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:719-789-5307
Mailing Address - Street 1:33688 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-7820
Mailing Address - Country:US
Mailing Address - Phone:707-217-3672
Mailing Address - Fax:
Practice Address - Street 1:2450 PERALTA BLVD STE 214
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-3826
Practice Address - Country:US
Practice Address - Phone:719-789-5307
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-31
Last Update Date:2025-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty