Healthcare Provider Details

I. General information

NPI: 1033802707
Provider Name (Legal Business Name): KAYLA JEAN MARTIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KJ MARTIN

II. Dates (important events)

Enumeration Date: 05/30/2023
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4311 N RAVENSWOOD AVE STE 305
CHICAGO IL
60613-1192
US

IV. Provider business mailing address

8140 WALNUT HILL LN STE 440
DALLAS TX
75231-4396
US

V. Phone/Fax

Practice location:
  • Phone: 469-709-9250
  • Fax:
Mailing address:
  • Phone: 469-709-9250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number69011
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.030273
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW61678234
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: