Provider Demographics
NPI:1083372940
Name:MARTINEZ, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MARTINEZ
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 1:5427 BLAZER CT
Mailing Address - Street 2:
Mailing Address - City:RIVERBANK
Mailing Address - State:CA
Mailing Address - Zip Code:95367-9429
Mailing Address - Country:US
Mailing Address - Phone:209-505-5546
Mailing Address - Fax:
Practice Address - Street 1:5427 BLAZER CT
Practice Address - Street 2:
Practice Address - City:RIVERBANK
Practice Address - State:CA
Practice Address - Zip Code:95367-9429
Practice Address - Country:US
Practice Address - Phone:209-505-5546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician