Provider Demographics
NPI:1992070775
Name:MARTIN, JENNIFER I (MA; CCC-SLP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:I
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MA; CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 N BERGIN LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NM
Mailing Address - Zip Code:87413-6729
Mailing Address - Country:US
Mailing Address - Phone:505-632-4389
Mailing Address - Fax:505-632-4371
Practice Address - Street 1:325 N BERGIN LN
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NM
Practice Address - Zip Code:87413-6729
Practice Address - Country:US
Practice Address - Phone:505-632-4389
Practice Address - Fax:505-632-4371
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1426235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000K7825Medicaid
NM064434826Medicaid