Provider Demographics
NPI:1104464775
Name:MARTINEZ, JACLYN (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:
Other - Last Name:VOLLMOELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5424 SILVER PINE CT
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-2744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3622 MORGANTON RD STE B
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-4967
Practice Address - Country:US
Practice Address - Phone:910-212-4441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-14
Last Update Date:2019-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0119131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical