Healthcare Provider Details

I. General information

NPI: 1548891310
Provider Name (Legal Business Name): JENNIFER ANN MARTINSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2020
Last Update Date: 02/23/2026
Certification Date: 02/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 CUMBERLAND AVE STE 225
LAFAYETTE IN
47906-1343
US

IV. Provider business mailing address

1305 CUMBERLAND AVE STE 225
LAFAYETTE IN
47906-1343
US

V. Phone/Fax

Practice location:
  • Phone: 657-204-2112
  • Fax:
Mailing address:
  • Phone: 765-204-2112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberT-25-6253
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: