Provider Demographics
NPI:1447723424
Name:MARTIN, AJHERA N
Entity type:Individual
Prefix:
First Name:AJHERA
Middle Name:N
Last Name:MARTIN
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 1:8030 S EBERHART AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-3810
Mailing Address - Country:US
Mailing Address - Phone:708-476-8106
Mailing Address - Fax:
Practice Address - Street 1:707 E 47TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-4201
Practice Address - Country:US
Practice Address - Phone:312-949-5521
Practice Address - Fax:312-538-5246
Is Sole Proprietor?:No
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL270000019101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health