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General NPI Number Information
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NPI Number | 1508313610
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Entity Type | Individual
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Provider Name | JACQUELINE MARTIN
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Gender | Female
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Dates
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Enumeration Date | 09/07/2016
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Last Update Date | 05/13/2025
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Provider Practice Location Address
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Address Line | 180 W B ST BLDG B2
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City | SPRINGFIELD
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State | OR
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Zip | 97477
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Country | US
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Telephone | 414-232-6335
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Fax | 541-299-5685
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Provider Business Mailing Address
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Address Line | 5411 E ST
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City | SPRINGFIELD
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State | OR
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Zip | 97478-6164
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Country | US
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Telephone | 440-665-5274
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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