Healthcare Provider Details

I. General information

NPI: 1417977802
Provider Name (Legal Business Name): JANICE DIANNE MARTIN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 06/01/2020
Certification Date: 06/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1891 OLD TRENTON ROAD
CLARKSVILLE TN
37040
US

IV. Provider business mailing address

PO BOX 30429
CLARKSVILLE TN
37040-0008
US

V. Phone/Fax

Practice location:
  • Phone: 931-552-4171
  • Fax: 931-551-9485
Mailing address:
  • Phone: 931-552-4171
  • Fax: 931-551-9485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2046
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number2046
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: