Provider Demographics
NPI:1144992603
Name:MARTIN, JESSE PAUL (LPC, NCC)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:PAUL
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 FONTANA AVE
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-4718
Mailing Address - Country:US
Mailing Address - Phone:717-269-0414
Mailing Address - Fax:
Practice Address - Street 1:1470 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ANNVILLE
Practice Address - State:PA
Practice Address - Zip Code:17003-1613
Practice Address - Country:US
Practice Address - Phone:717-964-7090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-04
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC013781101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health