Basic Information
| Provider Information | |||||||||
| NPI: | 1316281843 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8055 NW 104TH AVE APT 23 | ||||||||
| Address2: | |||||||||
| City: | DORAL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331784499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054900784 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3100 SW 62ND AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331553009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056666511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2012 | ||||||||
| LastUpdateDate: | 08/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA17743 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 100332500 | 05 | FL | MEDICAID |