Provider Demographics
NPI:1659062198
Name:JAXTIMER, MARTHA (LADC-I)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:JAXTIMER
Suffix:
Gender:F
Credentials:LADC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 56
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02541-0056
Mailing Address - Country:US
Mailing Address - Phone:774-255-0635
Mailing Address - Fax:
Practice Address - Street 1:400 NATHAN ELLIS HWY STE B
Practice Address - Street 2:
Practice Address - City:MASHPEE
Practice Address - State:MA
Practice Address - Zip Code:02649-3121
Practice Address - Country:US
Practice Address - Phone:774-255-0635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA471101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)