Provider Demographics
NPI:1649824756
Name:MARTIN, JENNIFER THERESE (SLP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:THERESE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 HENDRICKSON AVE
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-2829
Mailing Address - Country:US
Mailing Address - Phone:516-502-5135
Mailing Address - Fax:
Practice Address - Street 1:380 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:NY
Practice Address - Zip Code:11575-1845
Practice Address - Country:US
Practice Address - Phone:516-370-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028878235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist