Basic Information
| Provider Information | |||||||||
| NPI: | 1538544622 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 999 | ||||||||
| Address2: | |||||||||
| City: | PLACENTIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928710999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7143530873 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12440 FIRESTONE BLVD STE 316 | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906509319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628643722 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2015 | ||||||||
| LastUpdateDate: | 03/30/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 77555 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.