Provider Demographics
NPI:1417977802
Name:MARTIN, JANICE DIANNE (PHD)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:DIANNE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30429
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-0008
Mailing Address - Country:US
Mailing Address - Phone:931-552-4171
Mailing Address - Fax:931-551-9485
Practice Address - Street 1:1891 OLD TRENTON ROAD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040
Practice Address - Country:US
Practice Address - Phone:931-552-4171
Practice Address - Fax:931-551-9485
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2046103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3980231Medicare ID - Type Unspecified