Basic Information
| Provider Information | |||||||||
| NPI: | 1033505136 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LEANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MARTIN | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | LEANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 83 | ||||||||
| Address2: | |||||||||
| City: | CORNING | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724220083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708573334 | ||||||||
| FaxNumber: | 8708579934 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 COLONIAL DR | ||||||||
| Address2: | |||||||||
| City: | WALNUT RIDGE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724761410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708865507 | ||||||||
| FaxNumber: | 8708865632 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2015 | ||||||||
| LastUpdateDate: | 09/27/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 9579-M | AK | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 9579-C | AR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.