Provider Demographics
NPI:1841864485
Name:MARTIN, JEREMY (LISW-CP)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2712 MIDDLEBURG DR STE 207B
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2445
Mailing Address - Country:US
Mailing Address - Phone:803-274-3669
Mailing Address - Fax:
Practice Address - Street 1:2712 MIDDLEBURG DR STE 207B
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2445
Practice Address - Country:US
Practice Address - Phone:803-274-3669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11213104100000X
SC154931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker