Healthcare Provider Details

I. General information

NPI: 1740898295
Provider Name (Legal Business Name): JESSICA MARIE MARTIN PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2020
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8804 NW 127TH ST
OKLAHOMA CITY OK
73142-8623
US

IV. Provider business mailing address

921 NE 13TH ST
OKLAHOMA CITY OK
73104-5007
US

V. Phone/Fax

Practice location:
  • Phone: 254-723-7553
  • Fax:
Mailing address:
  • Phone: 254-723-7553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number101972
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: