Provider Demographics
NPI:1346709748
Name:MARTIN, JESSE (LPC MED)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LPC MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S WALNUT LN STE 201
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:PA
Mailing Address - Zip Code:15009-1737
Mailing Address - Country:US
Mailing Address - Phone:724-907-1667
Mailing Address - Fax:
Practice Address - Street 1:300 S WALNUT LN STE 201
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:PA
Practice Address - Zip Code:15009-1737
Practice Address - Country:US
Practice Address - Phone:724-907-1667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-15
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC010987101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional