Individual
MS. JESSICA LYNN MATIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DNP, APRN, ACNP-AG
Contact information
Practice address
GOODWIN HOUSE, 3440 S. JEFFERSON STREET, BAILEYS CROSSROADS, VA 22041-2204
(703) 820-1488
Mailing address
2101 MILL RD APT 113, ALEXANDRIA, VA 22314-5318
(573) 450-1334
Taxonomy
Speciality
Code
Description
License number
State
363LA2100X
Acute Care Nurse Practitioner
Primary
3010039
KY
363LG0600X
Gerontology Nurse Practitioner
3010039
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0000001021475
ANTHEM - NNIKY
KY
05
—
201391850
—
IN
01
—
215034
SIHO - NNIKY
LA
01
—
50112260
PASSPORT - NNIKY
KY
05
—
7100415610
—
KY
Enumeration date
06/07/2016
Last updated
08/15/2019
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