Provider Demographics
NPI:1407537681
Name:MARTINEZ, JESUS
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6413 28TH PL
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-2767
Mailing Address - Country:US
Mailing Address - Phone:630-697-9130
Mailing Address - Fax:
Practice Address - Street 1:7222 W. CERMAK RD. SUITE 500
Practice Address - Street 2:SUITE 500
Practice Address - City:NORTHRIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546
Practice Address - Country:US
Practice Address - Phone:866-695-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILBACB712171103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst