Provider Demographics
NPI:1801394325
Name:MARTIN, JESSICA LEIGH
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEIGH
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LEIGH
Other - Last Name:CRUZAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 568
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:MO
Mailing Address - Zip Code:65712-0568
Mailing Address - Country:US
Mailing Address - Phone:417-466-7844
Mailing Address - Fax:
Practice Address - Street 1:603 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:MO
Practice Address - Zip Code:65712-1074
Practice Address - Country:US
Practice Address - Phone:417-466-7844
Practice Address - Fax:417-466-2625
Is Sole Proprietor?:No
Enumeration Date:2018-01-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016034444104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker