Provider Demographics
NPI:1063232551
Name:MARTIN, JENNIFER L (PMHNP - BC)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:L
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PMHNP - BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4534 N MORGAN PL
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314
Mailing Address - Country:US
Mailing Address - Phone:928-499-2143
Mailing Address - Fax:
Practice Address - Street 1:726 GAIL GARDNER WAY
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305
Practice Address - Country:US
Practice Address - Phone:928-445-5211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-10
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN177597163W00000X
AZRNP315670363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse