Basic Information
Provider Information
NPI: 1033556147
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MARTIN
FirstName: JODIE
MiddleName: HELEN
NamePrefix: MS.
NameSuffix:  
Credential: LPC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 254 FARRINGTON AVE SE
Address2:  
City: ATLANTA
State: GA
PostalCode: 303151954
CountryCode: US
TelephoneNumber: 7703667670
FaxNumber:  
Practice Location
Address1: 254 FARRINGTON AVE SE
Address2:  
City: ATLANTA
State: GA
PostalCode: 303151954
CountryCode: US
TelephoneNumber: 7703667670
FaxNumber:  
Other Information
ProviderEnumerationDate: 05/30/2013
LastUpdateDate: 05/30/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YP2500XLPC007039GAY Behavioral Health & Social Service ProvidersCounselorProfessional

ID Information
IDTypeStateIssuerDescription
101YM0800X05GA MEDICAID


Home