Provider Demographics
NPI:1285099317
Name:MARTIN, JENNIFER (PSYD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4299 MACARTHUR BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2023
Mailing Address - Country:US
Mailing Address - Phone:949-791-7174
Mailing Address - Fax:
Practice Address - Street 1:4299 MACARTHUR BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2023
Practice Address - Country:US
Practice Address - Phone:949-791-7174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-16
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 27586103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist