Provider Demographics
NPI:1003334020
Name:MARTIN, JENNA (LAC)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1444 E CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-3839
Mailing Address - Country:US
Mailing Address - Phone:714-343-2185
Mailing Address - Fax:
Practice Address - Street 1:23421 S POINTE DR STE 275
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1555
Practice Address - Country:US
Practice Address - Phone:714-343-2185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-30
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC17710171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC17710OtherACUPUNCTURE BOARD CERTIFICATION