MEDICARE: MS. JESSICA ALYSSA MARTIN

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

General Provider Information

NPI Number	:	1629349600
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JESSICA ALYSSA MARTIN

Provider Business Mailing Address
First Line	:	260 WATKINS ST
Second Line	:
City	:	SWOYERSVILLE
State	:	PA
Zip	:	18704-2139
Country	:	US
Telephone Number	:	570-899-8278
Fax Number	:

Provider Business Practice Location Address
First Line	:	1172 TWIN STACKS DR # 427
Second Line	:
City	:	DALLAS
State	:	PA
Zip	:	18612-8505
Country	:	US
Telephone Number	:	570-674-1505
Fax Number	:	570-674-8679

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

Provider Enumeration Date	:	01/23/2012
Last Update Date	:	01/23/2012

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