Provider Demographics
NPI:1972707461
Name:MATTSON, JENNIFER LYNN (MPT)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:MATTSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:BOULTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:4262 JEFFERSON ST
Mailing Address - Street 2:APT 8115
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64111-4572
Mailing Address - Country:US
Mailing Address - Phone:816-331-9111
Mailing Address - Fax:
Practice Address - Street 1:924 N SCOTT AVE
Practice Address - Street 2:
Practice Address - City:BELTON
Practice Address - State:MO
Practice Address - Zip Code:64012-1739
Practice Address - Country:US
Practice Address - Phone:816-331-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006023029225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist