Provider Demographics
NPI:1497360416
Name:MARTINEZ, JESSICA GABRIELA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:GABRIELA
Last Name:MARTINEZ
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 1:3350 CONCOURS ST APT 27E
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-4891
Mailing Address - Country:US
Mailing Address - Phone:909-530-0202
Mailing Address - Fax:
Practice Address - Street 1:3350 CONCOURS APT 27E
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-4891
Practice Address - Country:US
Practice Address - Phone:909-530-0202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty