Provider Demographics
NPI:1154793883
Name:MARTIN, JASON
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4406 CHAMBERS RD
Mailing Address - Street 2:APT F11
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31206-4725
Mailing Address - Country:US
Mailing Address - Phone:478-461-1485
Mailing Address - Fax:
Practice Address - Street 1:4406 CHAMBERS RD
Practice Address - Street 2:APT F11
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31206-4725
Practice Address - Country:US
Practice Address - Phone:478-461-1485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-21
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor