Provider Demographics
NPI:1366165078
Name:MARTINEZ, JACKELINE (LPCC)
Entity type:Individual
Prefix:
First Name:JACKELINE
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 30TH ST APT E4-23
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-7500
Mailing Address - Country:US
Mailing Address - Phone:847-510-7464
Mailing Address - Fax:
Practice Address - Street 1:1455 DIXON AVE STE 300
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-8880
Practice Address - Country:US
Practice Address - Phone:303-443-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPCC.0019810101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health