Provider Demographics
NPI:1235537242
Name:MARTIN, PAMELA DELOACH (LPC)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:DELOACH
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1269 WINTERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-3136
Mailing Address - Country:US
Mailing Address - Phone:601-937-2618
Mailing Address - Fax:
Practice Address - Street 1:1269 WINTERVIEW DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-3136
Practice Address - Country:US
Practice Address - Phone:601-937-2618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAD07-044M101YA0400X
MS0818101YM0800X
MS1944101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health