Provider Demographics
NPI:1730713744
Name:MATA, JESSICA MARIA (BCABA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIA
Last Name:MATA
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11664 NW 90TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33018-4156
Mailing Address - Country:US
Mailing Address - Phone:305-842-4984
Mailing Address - Fax:
Practice Address - Street 1:4800 NW 167TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33014-6426
Practice Address - Country:US
Practice Address - Phone:305-515-2726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-28
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst