Basic Information
| Provider Information | |||||||||
| NPI: | 1225064850 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATKOWSKI | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | STANLEY | ||||||||
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| Credential: | LAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4253 N CROSSOVER RD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727034593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4795215731 | ||||||||
| FaxNumber: | 4795214926 | ||||||||
| Practice Location | |||||||||
| Address1: | 2003 SE WALTON BLVD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727123725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794648081 | ||||||||
| FaxNumber: | 4794640674 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | A0307064 | AR | X | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 3480 | OK | X | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.