Provider Demographics
NPI:1023391794
Name:JENNINGS, MARTHA (PT)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 OAKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75501-0963
Mailing Address - Country:US
Mailing Address - Phone:903-334-7476
Mailing Address - Fax:870-774-4790
Practice Address - Street 1:4824 MCKNIGHT RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-0935
Practice Address - Country:US
Practice Address - Phone:903-793-6135
Practice Address - Fax:903-793-0053
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1140978225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1140978OtherSTATE LICENSE NUMBER
AR195157721Medicaid
TX288237501Medicaid