Provider Demographics
NPI:1982971842
Name:MARTIN, JENNIFER LYNN (MA CCC/SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MA CCC/SLP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC/SLP
Mailing Address - Street 1:PO BOX 277
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34489-0277
Mailing Address - Country:US
Mailing Address - Phone:785-546-2599
Mailing Address - Fax:
Practice Address - Street 1:7232 SW 39TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-6624
Practice Address - Country:US
Practice Address - Phone:786-409-3254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-21
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-1267235Z00000X
FLSA11884235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810018692Medicaid
FL014269200Medicaid