Provider Demographics
NPI:1972174415
Name:MARTINEZ, JESSICA MONIQUE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MONIQUE
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3118
Mailing Address - Street 2:
Mailing Address - City:HELENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:92342-3118
Mailing Address - Country:US
Mailing Address - Phone:909-637-8861
Mailing Address - Fax:
Practice Address - Street 1:101 CIRBY HILLS DR
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-4360
Practice Address - Country:US
Practice Address - Phone:916-787-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA951781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical