Provider Demographics
NPI:1831309269
Name:MARTIN, JACK (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7633 LOVAIN DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78414-6159
Mailing Address - Country:US
Mailing Address - Phone:361-992-1212
Mailing Address - Fax:
Practice Address - Street 1:5934 S STAPLES ST
Practice Address - Street 2:SUITE 210
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78413-3842
Practice Address - Country:US
Practice Address - Phone:361-992-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2311101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health