Provider Demographics
NPI:1417590589
Name:MARTIN, JESSICA SERENE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SERENE
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 1:212 N COURT ST
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:WV
Mailing Address - Zip Code:25570-1141
Mailing Address - Country:US
Mailing Address - Phone:304-272-5116
Mailing Address - Fax:304-272-5993
Practice Address - Street 1:212 N COURT ST
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:WV
Practice Address - Zip Code:25570-1141
Practice Address - Country:US
Practice Address - Phone:304-272-5116
Practice Address - Fax:304-272-5993
Is Sole Proprietor?:No
Enumeration Date:2019-10-22
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVN3E143300096103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool