| Doctor Name: | MRS. JACKIE LYNN MATHIESEN |
| NPI Number: | 1952441602 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | M.S. CCC-SLP |
| License Number: | SLP4480 |
| Business Practice Address: | 12409 W Indian School Rd Ste C306 Avondale, AZ - 853239508 |
| Business Phone Number: | 6239356040 |
| Business Fax Number: | |
| Mailing Address: | 14408 W Desert Cove Rd, SURPRISE |
| State: | AZ |
| Postal Code: | 853794334 |
| Phone Number: | |
| Fax Number: | |
| NPI Enumeration Date: | 02/08/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 235Z00000X |
| License Number: | SLP4480 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | AZ |
| Taxonomy Type: | Speech, Language and Hearing Service Providers |
| Taxonomy Classification: | Speech-Language Pathologist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A speech pathologist is a person qualified by a master |