Provider Demographics
NPI:1588457964
Name:MARTINEZ, JACKELINE
Entity type:Individual
Prefix:
First Name:JACKELINE
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2617 SOL DE VIDA NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-1333
Mailing Address - Country:US
Mailing Address - Phone:505-544-9913
Mailing Address - Fax:
Practice Address - Street 1:2617 SOL DE VIDA NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-1333
Practice Address - Country:US
Practice Address - Phone:505-544-9913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-27
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM516624477106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician