Healthcare Provider Details

I. General information

NPI: 1386397446
Provider Name (Legal Business Name): JENNYMAE MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2022
Last Update Date: 06/06/2024
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 5723
PASADENA CA
91117-0723
US

IV. Provider business mailing address

PO BOX 5723
PASADENA CA
91117-0723
US

V. Phone/Fax

Practice location:
  • Phone: 603-770-2360
  • Fax:
Mailing address:
  • Phone: 603-770-2360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPCC10671
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPCC16376
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: