Provider Demographics
NPI:1558400739
Name:MARTIN, JEFFERY R (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:R
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1010 SIR FRANCIS DRAKE BLVD
Mailing Address - Street 2:SUITE 2E
Mailing Address - City:KENTFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94904-1417
Mailing Address - Country:US
Mailing Address - Phone:415-461-3175
Mailing Address - Fax:707-579-1945
Practice Address - Street 1:1010 SIR FRANCIS DRAKE BLVD
Practice Address - Street 2:SUITE 2E
Practice Address - City:KENTFIELD
Practice Address - State:CA
Practice Address - Zip Code:94904-1417
Practice Address - Country:US
Practice Address - Phone:415-461-3175
Practice Address - Fax:707-579-1945
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY4872103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical