Provider Demographics
NPI:1861163636
Name:MATILSKY, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MATILSKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13518 NW 2ND LN APT 209
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32669-3707
Mailing Address - Country:US
Mailing Address - Phone:352-339-4881
Mailing Address - Fax:
Practice Address - Street 1:3450 HULL RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-4144
Practice Address - Country:US
Practice Address - Phone:352-273-7394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FL11020824363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program