Healthcare Provider Details

I. General information

NPI: 1730421058
Provider Name (Legal Business Name): JENNIFER H. MARTIN MA LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER H. STREETER MA LPCC

II. Dates (important events)

Enumeration Date: 03/25/2013
Last Update Date: 10/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4811 S 76TH ST SUITE 401
GREENFIELD WI
53220-4364
US

IV. Provider business mailing address

4811 S 76TH ST SUITE 401
GREENFIELD WI
53220-4364
US

V. Phone/Fax

Practice location:
  • Phone: 414-325-7741
  • Fax: 414-325-7753
Mailing address:
  • Phone: 414-325-7741
  • Fax: 414-325-7753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.1000114
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: