Healthcare Provider Details

I. General information

NPI: 1316307028
Provider Name (Legal Business Name): JENNIFER MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2016
Last Update Date: 05/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 N JEFFERSON DAVIS PKWY
NEW ORLEANS LA
70119-5312
US

IV. Provider business mailing address

6574 FLEUR DE LIS DR APT 20
NEW ORLEANS LA
70124-1492
US

V. Phone/Fax

Practice location:
  • Phone: 504-948-6880
  • Fax: 504-278-4007
Mailing address:
  • Phone: 504-210-9958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: