Provider Demographics
NPI:1134737448
Name:MARTINEZ, JACQUELINE MARIE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIE
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 1:4316 GERMAN POINTER WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76123-3556
Mailing Address - Country:US
Mailing Address - Phone:817-269-7037
Mailing Address - Fax:
Practice Address - Street 1:1605 GRADY LEE ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76134-1115
Practice Address - Country:US
Practice Address - Phone:817-814-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-22
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX414952355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant