Healthcare Provider Details

I. General information

NPI: 1053046557
Provider Name (Legal Business Name): JONATHAN L MARTINEZ LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2022
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12021 METRIC BLVD
AUSTIN TX
78758-8616
US

IV. Provider business mailing address

1680 HERO WAY APT 1212
LEANDER TX
78641-3429
US

V. Phone/Fax

Practice location:
  • Phone: 512-228-3308
  • Fax: 512-228-3349
Mailing address:
  • Phone: 432-290-3019
  • Fax: 512-228-3308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number66801
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: