Provider Demographics
NPI:1306059522
Name:MARTINEZ, JESSE S (LISW)
Entity type:Individual
Prefix:MR
First Name:JESSE
Middle Name:S
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:MR
Other - First Name:JESSE
Other - Middle Name:S
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LISW
Mailing Address - Street 1:577 EL LLANO RD
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2911
Mailing Address - Country:US
Mailing Address - Phone:505-753-1656
Mailing Address - Fax:
Practice Address - Street 1:577 EL LLANO RD
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2911
Practice Address - Country:US
Practice Address - Phone:505-753-1656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-3701104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker