Provider Demographics
NPI:1073667226
Name:MARTIN, JACQUELINE WILSON
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:WILSON
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 1:210 S VAN BUREN RD
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-5025
Mailing Address - Country:US
Mailing Address - Phone:336-577-2173
Mailing Address - Fax:336-589-1320
Practice Address - Street 1:538 WARRINER ST
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-3053
Practice Address - Country:US
Practice Address - Phone:336-348-6902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-079-037177F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes177F00000XOther Service ProvidersLodging
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7803777Medicaid