Provider Demographics
NPI:1467717728
Name:MARTIN, JASON R (LCPC, CPRP)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:R
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LCPC, CPRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14901 BROSCHART RD
Mailing Address - Street 2:ADVENTIST BEHAVIORAL HEALTH
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3318
Mailing Address - Country:US
Mailing Address - Phone:301-251-4638
Mailing Address - Fax:
Practice Address - Street 1:14901 BROSCHART RD
Practice Address - Street 2:ADVENTIST BEHAVIORAL HEALTH
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3318
Practice Address - Country:US
Practice Address - Phone:301-251-4638
Practice Address - Fax:301-840-1348
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC4470101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD816700100Medicaid