Provider Demographics
NPI:1609568310
Name:MARTINEZ, JORDAN D'ANGELO
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:D'ANGELO
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8690 SW 14TH CT
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3382
Mailing Address - Country:US
Mailing Address - Phone:754-332-5774
Mailing Address - Fax:
Practice Address - Street 1:8690 SW 14TH CT
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33025-3382
Practice Address - Country:US
Practice Address - Phone:754-332-5774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-274359106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician