Healthcare Provider Details

I. General information

NPI: 1922424183
Provider Name (Legal Business Name): JEANNE MARTINEZ M.A, L.A.D.A.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2014
Last Update Date: 03/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 LUCIA LN
SANTA FE NM
87507-3000
US

IV. Provider business mailing address

4100 LUCIA LN
SANTA FE NM
87507-3000
US

V. Phone/Fax

Practice location:
  • Phone: 505-471-4985
  • Fax: 505-471-6084
Mailing address:
  • Phone: 505-471-4985
  • Fax: 505-471-6084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number4779
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: