Provider Demographics
NPI:1902332240
Name:JAYA MATHEW PHD, PLLC
Entity Type:Organization
Organization Name:JAYA MATHEW PHD, PLLC
Other - Org Name:WELLLNESS 360
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAYA
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHEW
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:214-755-7532
Mailing Address - Street 1:1340 PRUDENTIAL DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-4115
Mailing Address - Country:US
Mailing Address - Phone:214-755-7532
Mailing Address - Fax:
Practice Address - Street 1:1340 PRUDENTIAL DR
Practice Address - Street 2:SUITE A
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-4115
Practice Address - Country:US
Practice Address - Phone:214-755-7532
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-05
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36584103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty