Provider Demographics
NPI:1316307028
Name:MARTIN, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6574 FLEUR DE LIS DR APT 20
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70124-1492
Mailing Address - Country:US
Mailing Address - Phone:504-210-9958
Mailing Address - Fax:
Practice Address - Street 1:330 N JEFFERSON DAVIS PKWY
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-5312
Practice Address - Country:US
Practice Address - Phone:504-948-6880
Practice Address - Fax:504-278-4007
Is Sole Proprietor?:No
Enumeration Date:2016-02-24
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
LA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No172V00000XOther Service ProvidersCommunity Health Worker