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General NPI Number Information
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NPI Number | 1528521028
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Entity Type | Individual
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Provider Name | JASON TIMOTHY MARTIN LPC, NCC
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Gender | Male
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Dates
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Enumeration Date | 04/11/2019
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Last Update Date | 11/28/2023
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Provider Practice Location Address
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Address Line | 351 WAGONER DR STE 418
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City | FAYETTEVILLE
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State | NC
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Zip | 28303-4608
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Country | US
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Telephone | 910-580-4973
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Fax | 855-940-0214
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Provider Business Mailing Address
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Address Line | 351 WAGONER DR STE 418
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City | FAYETTEVILLE
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State | NC
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Zip | 28303-4608
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Country | US
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Telephone | 910-580-4973
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Fax | 855-940-0214
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 14728
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License Number State | NC
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