MEDICARE: JESSICA MARILYN MARTINEZ LCSW

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	1041C0700X	Clinical Social Worker	SW13782	FL
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1447763743
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA MARILYN MARTINEZ LCSW

Provider Business Mailing Address
First Line	:	1123 ELMWOOD ST
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32801-4058
Country	:	US
Telephone Number	:	407-257-4081
Fax Number	:

Provider Business Practice Location Address
First Line	:	1758 E MICHIGAN ST
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32806-4935
Country	:	US
Telephone Number	:	407-836-7650
Fax Number	:

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

Provider Enumeration Date	:	11/08/2017
Last Update Date	:	11/08/2017

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