Provider Demographics
NPI:1881020592
Name:MARTIN, JEANETTE (MA, CCC-SLP, TSSLD)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MA, CCC-SLP, TSSLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782-2808
Mailing Address - Country:US
Mailing Address - Phone:631-889-0288
Mailing Address - Fax:
Practice Address - Street 1:63 SUNSET DR
Practice Address - Street 2:
Practice Address - City:SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11782-2808
Practice Address - Country:US
Practice Address - Phone:631-889-0288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-25
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist