Provider Demographics
NPI:1104214824
Name:MARTIN, JENNIFER DAWN (LPCC)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:DAWN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3040 RIVERSIDE DR STE 218
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43221-2551
Mailing Address - Country:US
Mailing Address - Phone:614-636-0334
Mailing Address - Fax:614-548-8663
Practice Address - Street 1:3040 RIVERSIDE DR STE 218
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-2579
Practice Address - Country:US
Practice Address - Phone:614-636-0334
Practice Address - Fax:614-548-8663
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-05
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE. 1200549101YP2500X, 101YM0800X
261QM0801X, 261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1104214824Medicaid