Provider Demographics
NPI:1518724582
Name:MARTIN, JACLYN BLAINE (LMSW)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:BLAINE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2116 DEL LAGO CIR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-8286
Mailing Address - Country:US
Mailing Address - Phone:770-685-9192
Mailing Address - Fax:
Practice Address - Street 1:2116 DEL LAGO CIR NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-8286
Practice Address - Country:US
Practice Address - Phone:770-685-9192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW006720104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker