Healthcare Provider Details

I. General information

NPI: 1700385986
Provider Name (Legal Business Name): JESSICA MARTA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2018
Last Update Date: 02/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 VARICK ST FL 9
NEW YORK NY
10014-4810
US

IV. Provider business mailing address

60 THAYER ST APT 3M
NEW YORK NY
10040-1139
US

V. Phone/Fax

Practice location:
  • Phone: 212-620-0340
  • Fax:
Mailing address:
  • Phone: 917-816-8642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number402265
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF402265
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: