Provider Demographics
NPI:1053684233
Name:MARTINEZ, JAIME
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 28220
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87592-8220
Mailing Address - Country:US
Mailing Address - Phone:505-471-5006
Mailing Address - Fax:
Practice Address - Street 1:1302 CALLE DE LA MERCED
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2624
Practice Address - Country:US
Practice Address - Phone:505-747-0081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-17
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-07758104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker