MEDICARE: JENNIFER LEE MARTIN LCSW, LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	18899	TX
2	106H00000X	Marriage & Family Therapist	3030	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	238896	OTHER	TX	TRICARE

General Provider Information

NPI Number	:	1720131444
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER LEE MARTIN LCSW, LMFT

Provider Business Mailing Address
First Line	:	6825 HOLIDAY LN
Second Line	:
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78414-2724
Country	:	US
Telephone Number	:	361-658-5992
Fax Number	:	361-992-4655

Provider Business Practice Location Address
First Line	:	509 LAWRENCE ST STE 303
Second Line	:
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78401-2573
Country	:	US
Telephone Number	:	361-658-5992
Fax Number	:	361-992-4655

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	07/30/2007

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