Provider Demographics
NPI:1174186159
Name:MARTIN, JESSICA DANIELLE (MSW, LMSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DANIELLE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17426 LORANGER ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1778
Mailing Address - Country:US
Mailing Address - Phone:586-805-8028
Mailing Address - Fax:
Practice Address - Street 1:7640 DIXIE HWY STE 155
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-2095
Practice Address - Country:US
Practice Address - Phone:248-791-9266
Practice Address - Fax:248-392-2601
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011149991041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical