Provider Demographics
NPI:1528521028
Name:MARTIN, JASON TIMOTHY (LPC, NCC)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:TIMOTHY
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 WAGONER DR STE 418
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-4608
Mailing Address - Country:US
Mailing Address - Phone:910-580-4973
Mailing Address - Fax:855-940-0214
Practice Address - Street 1:351 WAGONER DR STE 418
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-4608
Practice Address - Country:US
Practice Address - Phone:910-580-4973
Practice Address - Fax:855-940-0214
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-11
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14728101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health