Provider Demographics
NPI:1740904952
Name:MARTIN, JENNIFER (LCMHCA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 BROOK CROSSING CIR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27606-3169
Mailing Address - Country:US
Mailing Address - Phone:716-400-4382
Mailing Address - Fax:
Practice Address - Street 1:871 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27605-1499
Practice Address - Country:US
Practice Address - Phone:919-229-9834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-30
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA17986101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health