Provider Demographics
NPI:1548519762
Name:MATALA, JESSICA NICOLE (LGSW)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:NICOLE
Last Name:MATALA
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3312
Mailing Address - Country:US
Mailing Address - Phone:304-685-8967
Mailing Address - Fax:
Practice Address - Street 1:509 LAKE ST
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3312
Practice Address - Country:US
Practice Address - Phone:304-685-8967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-04
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP00944408104100000X
SW129846104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker