Healthcare Provider Details

I. General information

NPI: 1760228027
Provider Name (Legal Business Name): JESSICA MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2024
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 IOWA AVE STE 101
RIVERSIDE CA
92507-7428
US

IV. Provider business mailing address

2020 IOWA AVE STE 101
RIVERSIDE CA
92507-7428
US

V. Phone/Fax

Practice location:
  • Phone: 951-580-1026
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number21463
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: