Healthcare Provider Details

I. General information

NPI: 1992336556
Provider Name (Legal Business Name): JESSICA ANNE MARTIN MSW, LSWAIC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2020
Last Update Date: 12/15/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12112 E ALKI AVE APT 11
SPOKANE VALLEY WA
99206-5189
US

IV. Provider business mailing address

12112 E ALKI AVE APT 11
SPOKANE VALLEY WA
99206-5189
US

V. Phone/Fax

Practice location:
  • Phone: 509-714-2143
  • Fax:
Mailing address:
  • Phone: 509-714-2143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number61131132
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: