1780496323 NPI number — JESSICA MICHELLE MARTINEZ

Table of content: JESSICA MICHELLE MARTINEZ (NPI 1780496323)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780496323 NPI number — JESSICA MICHELLE MARTINEZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTINEZ
Provider First Name:
JESSICA
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780496323
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2905 MASSENGALE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEBSTER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77598-5806
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-978-0018
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1414 S FRIENDSWOOD DR STE 118A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRIENDSWOOD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77546-2250
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-978-0018
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/21/2025

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  94086 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 94086 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 94086 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)