Provider Demographics
NPI:1356718654
Name:MARTINEZ, JACOB ANTHONY
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ANTHONY
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7485 N PALM AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-5764
Mailing Address - Country:US
Mailing Address - Phone:559-221-8100
Mailing Address - Fax:559-221-8101
Practice Address - Street 1:7485 N PALM AVE STE 103
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-5764
Practice Address - Country:US
Practice Address - Phone:559-221-8100
Practice Address - Fax:559-221-8101
Is Sole Proprietor?:No
Enumeration Date:2015-08-21
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA8253973101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)