Provider Demographics
NPI:1679064174
Name:MARTIN, JESSICA SUE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SUE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 BRINDLESTONE DR
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:OH
Mailing Address - Zip Code:45377-3104
Mailing Address - Country:US
Mailing Address - Phone:937-344-6594
Mailing Address - Fax:
Practice Address - Street 1:7695 S COUNTY ROAD 25A
Practice Address - Street 2:
Practice Address - City:TIPP CITY
Practice Address - State:OH
Practice Address - Zip Code:45371-9215
Practice Address - Country:US
Practice Address - Phone:937-667-4678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health