Provider Demographics
NPI:1053454140
Name:MARTIN, KIM JACOBS (DC)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:JACOBS
Last Name:MARTIN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1446 TECHNY RD
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-5447
Mailing Address - Country:US
Mailing Address - Phone:847-736-9555
Mailing Address - Fax:847-386-6270
Practice Address - Street 1:1446 TECHNY RD
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-5447
Practice Address - Country:US
Practice Address - Phone:847-736-9555
Practice Address - Fax:847-386-6270
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.011644111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSU79952Medicare UPIN
KS00A364AMedicare ID - Type Unspecified