=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275845596
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER SUE MARTINEZ PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2010
-----------------------------------------------------
Last Update Date | 12/11/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 170 E 300 S
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84653-9453
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-616-2825
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 728
-----------------------------------------------------
City | SPANISH FORK
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84660-0728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-616-2825
-----------------------------------------------------
Fax | 510-380-3195
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 7718070-2501
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------