Provider Demographics
NPI:1174931463
Name:MATTHESEN, JENNIFER BERRY (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:BERRY
Last Name:MATTHESEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:ANNE
Other - Last Name:BERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:118 GOOD HILL RD
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:CT
Mailing Address - Zip Code:06883-2809
Mailing Address - Country:US
Mailing Address - Phone:203-221-9126
Mailing Address - Fax:203-557-9012
Practice Address - Street 1:118 GOOD HILL RD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:CT
Practice Address - Zip Code:06883-2809
Practice Address - Country:US
Practice Address - Phone:203-221-9126
Practice Address - Fax:203-557-9012
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-30
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY277360208600000X
CT53345208600000X
CAA83217208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery