Healthcare Provider Details

I. General information

NPI: 1386212967
Provider Name (Legal Business Name): JAMIE L MARTINEZ LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2021
Last Update Date: 06/11/2021
Certification Date: 06/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1335 GUSDORF ROAD BLDG E
TAOS NM
87571
US

IV. Provider business mailing address

PO BOX 788
ESPANOLA NM
87532
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-0670
  • Fax: 575-751-3557
Mailing address:
  • Phone: 505-927-8397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM-08415
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: