MEDICARE: DR. JACQUELINE ROSE MARTIN ED.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MI1128	NV

General Provider Information

NPI Number	:	1194282723
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACQUELINE ROSE MARTIN ED.D.

Provider Business Mailing Address
First Line	:	1613 INDIAN COVE LN
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-7313
Country	:	US
Telephone Number	:	562-370-6849
Fax Number	:

Provider Business Practice Location Address
First Line	:	2755 E DESERT INN RD STE 250
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-3610
Country	:	US
Telephone Number	:	702-538-9474
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/01/2019
Last Update Date	:	03/01/2019

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Directions to “ DR. JACQUELINE ROSE MARTIN ED.D.” Practice Location

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