Provider Demographics
NPI:1033684899
Name:MATTOX, KRYSTAL JADE (LPC)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:JADE
Last Name:MATTOX
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621 ENTERPRISE DR OFC 5
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-5797
Mailing Address - Country:US
Mailing Address - Phone:434-239-4949
Mailing Address - Fax:434-239-4955
Practice Address - Street 1:1621 ENTERPRISE DR OFC 5
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-5797
Practice Address - Country:US
Practice Address - Phone:434-239-4949
Practice Address - Fax:434-239-4955
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional