Healthcare Provider Details

I. General information

NPI: 1275845596
Provider Name (Legal Business Name): JENNIFER SUE MARTINEZ PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2010
Last Update Date: 12/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 E 300 S
SALEM UT
84653-9453
US

IV. Provider business mailing address

PO BOX 728
SPANISH FORK UT
84660-0728
US

V. Phone/Fax

Practice location:
  • Phone: 801-616-2825
  • Fax:
Mailing address:
  • Phone: 801-616-2825
  • Fax: 510-380-3195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number7718070-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: