Healthcare Provider Details

I. General information

NPI: 1508313610
Provider Name (Legal Business Name): JACQUELINE MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 05/13/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 W B ST BLDG B2
SPRINGFIELD OR
97477
US

IV. Provider business mailing address

5411 E ST
SPRINGFIELD OR
97478-6164
US

V. Phone/Fax

Practice location:
  • Phone: 414-232-6335
  • Fax: 541-299-5685
Mailing address:
  • Phone: 440-665-5274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: