Provider Demographics
NPI:1003295239
Name:MARTIN, JENNIFER LEE (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751461
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29425-3230
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:
Practice Address - Street 1:171 ASHLEY AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-3230
Practice Address - Country:US
Practice Address - Phone:843-792-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-20
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT016512207R00000X
SC390922085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine