Provider Demographics
NPI:1194331884
Name:MARTIN, JESSICA AFTON (LLMSW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:AFTON
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:AFTON
Other - Last Name:ROOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3899 OKEMOS RD STE A1
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-3666
Mailing Address - Country:US
Mailing Address - Phone:517-507-5892
Mailing Address - Fax:
Practice Address - Street 1:3899 OKEMOS RD STE A1
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3666
Practice Address - Country:US
Practice Address - Phone:517-507-5892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011003931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty