Provider Demographics
NPI:1780104588
Name:MARTINEZ, JONATHAN MICHAEL
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MICHAEL
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 MANZANO ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-6302
Mailing Address - Country:US
Mailing Address - Phone:505-925-4353
Mailing Address - Fax:505-925-4354
Practice Address - Street 1:618 MANZANO ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-6302
Practice Address - Country:US
Practice Address - Phone:505-925-4353
Practice Address - Fax:505-925-4354
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NM171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM78670781Medicaid