Provider Demographics
NPI:1124261490
Name:MARTIN, JESSE CARROLL (MS, CCC/SLP)
Entity type:Individual
Prefix:MR
First Name:JESSE
Middle Name:CARROLL
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MS, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1526 E 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-5510
Mailing Address - Country:US
Mailing Address - Phone:509-473-9672
Mailing Address - Fax:
Practice Address - Street 1:1526 E 7TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-5510
Practice Address - Country:US
Practice Address - Phone:509-473-9672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-15
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL 00003312235Z00000X
IDSLP-1788235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist