Provider Demographics
NPI:1508313610
Name:MARTIN, JACQUELINE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MARTIN
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 1:5411 E ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97478-6164
Mailing Address - Country:US
Mailing Address - Phone:440-665-5274
Mailing Address - Fax:
Practice Address - Street 1:180 W B ST
Practice Address - Street 2:BLDG B2
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477
Practice Address - Country:US
Practice Address - Phone:414-232-6335
Practice Address - Fax:541-299-5685
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical