Healthcare Provider Details

I. General information

NPI: 1912268384
Provider Name (Legal Business Name): MICHAEL JACK MARTIN MA MFTI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2012
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 PEARL ST
EUGENE OR
97401-4010
US

IV. Provider business mailing address

1551 PEARL ST
EUGENE OR
97401-4010
US

V. Phone/Fax

Practice location:
  • Phone: 541-517-9733
  • Fax:
Mailing address:
  • Phone: 541-517-9733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberT2450
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number97189
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: