Basic Information
| Provider Information | |||||||||
| NPI: | 1649799495 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTELL | ||||||||
| FirstName: | JERYCA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 647 13TH AVE E STE A | ||||||||
| Address2: | |||||||||
| City: | WEST FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 580783328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012778844 | ||||||||
| FaxNumber: | 7012778847 | ||||||||
| Practice Location | |||||||||
| Address1: | 4725 AMBER VALLEY PKWY S STE B | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581048614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7014780221 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2017 | ||||||||
| LastUpdateDate: | 11/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.