Provider Demographics
NPI:1659642676
Name:MARTIN, JESSICA HERSHEY (LGSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:HERSHEY
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 WABASH AVE
Mailing Address - Street 2:APARTMENT 1
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-6775
Mailing Address - Country:US
Mailing Address - Phone:301-641-0274
Mailing Address - Fax:
Practice Address - Street 1:3930 KNOWLES AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-2428
Practice Address - Country:US
Practice Address - Phone:301-641-0274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15484104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker