Provider Demographics
NPI:1174186159
Name:MARTIN, JESSICA DANIELLE (MSW, LMSW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:DANIELLE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17426 LORANGER ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1778
Mailing Address - Country:US
Mailing Address - Phone:586-805-8028
Mailing Address - Fax:
Practice Address - Street 1:30503 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-1594
Practice Address - Country:US
Practice Address - Phone:248-691-4744
Practice Address - Fax:248-691-8129
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801114999104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker