Provider Demographics
NPI:1417263492
Name:MARTIN, JODIE LYNN (MED, LPC)
Entity Type:Individual
Prefix:MRS
First Name:JODIE
Middle Name:LYNN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2402 CANYON LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79415-2000
Mailing Address - Country:US
Mailing Address - Phone:806-762-5782
Mailing Address - Fax:
Practice Address - Street 1:2402 CANYON LAKE DR
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79415-2000
Practice Address - Country:US
Practice Address - Phone:806-762-5782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64653101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional