Provider Demographics
NPI:1740898295
Name:MARTIN, JESSICA MARIE (PSYD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:MARIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 NE 13TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5007
Mailing Address - Country:US
Mailing Address - Phone:254-723-7553
Mailing Address - Fax:
Practice Address - Street 1:8804 NW 127TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73142-8623
Practice Address - Country:US
Practice Address - Phone:254-723-7553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA101972103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical