Basic Information
| Provider Information | |||||||||
| NPI: | 1790148427 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATTOX | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GLATZ | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 234 CROOKED CREEK PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277138506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195446644 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 234 CROOKED CREEK PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277138506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195446644 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2016 | ||||||||
| LastUpdateDate: | 11/04/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 2020-03216 | NC | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 2020-03216 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.