Provider Demographics
NPI:1710239942
Name:JENELLE MARTIN, M.D., P.C.
Entity Type:Organization
Organization Name:JENELLE MARTIN, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JENELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-638-1960
Mailing Address - Street 1:PO BOX 871133
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-0029
Mailing Address - Country:US
Mailing Address - Phone:770-638-1960
Mailing Address - Fax:770-638-1961
Practice Address - Street 1:3469 LAWRENCEVILLE HWY
Practice Address - Street 2:SUITE 103
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5888
Practice Address - Country:US
Practice Address - Phone:770-638-1960
Practice Address - Fax:770-638-1961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034660261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA26BDFHMMedicare UPIN