Provider Demographics
NPI:1033567599
Name:MARTIN, JESSAMINE (PSYD)
Entity Type:Individual
Prefix:
First Name:JESSAMINE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1480 BOSTON POST RD
Mailing Address - Street 2:
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-1750
Mailing Address - Country:US
Mailing Address - Phone:800-370-3651
Mailing Address - Fax:877-515-7147
Practice Address - Street 1:2595 INTERSTATE DR STE 103
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17110-9378
Practice Address - Country:US
Practice Address - Phone:800-370-3651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS018877103TC0700X
NE10865101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health