Provider Demographics
NPI:1720131444
Name:MARTIN, JENNIFER LEE (LCSW, LMFT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LCSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6825 HOLIDAY LN
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78414-2724
Mailing Address - Country:US
Mailing Address - Phone:361-658-5992
Mailing Address - Fax:361-992-4655
Practice Address - Street 1:509 LAWRENCE ST STE 303
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78401-2573
Practice Address - Country:US
Practice Address - Phone:361-658-5992
Practice Address - Fax:361-992-4655
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX188991041C0700X
TX3030106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX238896OtherTRICARE
TX00174PMedicare UPIN