Provider Demographics
NPI:1255675906
Name:MARTIN, JAQUELINE
Entity Type:Individual
Prefix:
First Name:JAQUELINE
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 1:9435 FEATHER WAY
Mailing Address - Street 2:
Mailing Address - City:DELHI
Mailing Address - State:CA
Mailing Address - Zip Code:95315-9328
Mailing Address - Country:US
Mailing Address - Phone:209-585-7166
Mailing Address - Fax:
Practice Address - Street 1:9435 FEATHER WAY
Practice Address - Street 2:
Practice Address - City:DELHI
Practice Address - State:CA
Practice Address - Zip Code:95315-9328
Practice Address - Country:US
Practice Address - Phone:209-585-7166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-19
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA118978104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker