Provider Demographics
NPI:1689898793
Name:MARTIN, JENNIE (LICSW)
Entity type:Individual
Prefix:MS
First Name:JENNIE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:JENNIE
Other - Middle Name:
Other - Last Name:NAGELHOUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10 DAVOL SQ
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4754
Mailing Address - Country:US
Mailing Address - Phone:401-421-4000
Mailing Address - Fax:401-272-1456
Practice Address - Street 1:900 WARREN AVE
Practice Address - Street 2:SUITE 401
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-1430
Practice Address - Country:US
Practice Address - Phone:800-508-4908
Practice Address - Fax:401-228-6236
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW012411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI62-60201Medicare UPIN
RI1039560Medicare UPIN
RI26421-3Medicare UPIN
809003702Medicare ID - Type UnspecifiedMEDICARE