Provider Demographics
NPI:1912202045
Name:MARTIN, JACQUELINE MARIE (LMHC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 HARVARD ST
Mailing Address - Street 2:APT. 5
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14607-3170
Mailing Address - Country:US
Mailing Address - Phone:585-313-3255
Mailing Address - Fax:
Practice Address - Street 1:194 HARVARD ST
Practice Address - Street 2:APT. 5
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607-3170
Practice Address - Country:US
Practice Address - Phone:585-313-3255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004202-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health