Provider Demographics
NPI:1083174627
Name:MARTIN, ROBERTA
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 E 46TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-5482
Mailing Address - Country:US
Mailing Address - Phone:904-610-3727
Mailing Address - Fax:
Practice Address - Street 1:1536 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6525
Practice Address - Country:US
Practice Address - Phone:904-470-6900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
1386008407OtherMILITARY