Provider Demographics
NPI:1942451703
Name:MARTIN, JESSICA (LISW-S)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:899 E BROAD ST FL 3
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-1156
Mailing Address - Country:US
Mailing Address - Phone:614-355-8000
Mailing Address - Fax:614-355-8018
Practice Address - Street 1:390 N SPRING RD
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-1888
Practice Address - Country:US
Practice Address - Phone:614-797-6633
Practice Address - Fax:614-797-6601
Is Sole Proprietor?:No
Enumeration Date:2008-10-09
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS0700385104100000X
OHI.0900208-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH08258Medicaid