Provider Demographics
NPI:1669037883
Name:MARTIN, JESSICA ALLYSSA
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ALLYSSA
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:ALLYSSA
Other - Last Name:STEFFAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:855 THIRD AVE SUITE 2230
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911
Mailing Address - Country:US
Mailing Address - Phone:760-822-9946
Mailing Address - Fax:
Practice Address - Street 1:855 THIRD AVE SUITE 2230
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911
Practice Address - Country:US
Practice Address - Phone:760-822-9946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-02
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA117187106H00000X
CALMFT117187101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA104313OtherBOARD OF BEHAVIORAL SCIENCES
CA117187OtherBOARD OF BEHAVIORAL SCIENCES