Provider Demographics
NPI:1497262208
Name:MARTIN, JENNIFER (EDS, NCSP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:EDS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6141 N KEATING AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-4903
Mailing Address - Country:US
Mailing Address - Phone:773-427-0794
Mailing Address - Fax:
Practice Address - Street 1:2031 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2401
Practice Address - Country:US
Practice Address - Phone:224-765-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-02
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1842735103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1842735OtherIL STATE BOARD OF ED - PROFESSIONAL EDUCATOR LICENSE