Provider Demographics
NPI:1972911162
Name:MARTIN, JENNIE (PSYD)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PSYD
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 8101
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93409-8101
Mailing Address - Country:US
Mailing Address - Phone:805-547-7900
Mailing Address - Fax:
Practice Address - Street 1:COLONY DR
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93409-0001
Practice Address - Country:US
Practice Address - Phone:805-547-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-31
Last Update Date:2024-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY27763103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic