Provider Demographics
NPI:1164871182
Name:MARTIN, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
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 1:28304 PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-7312
Mailing Address - Country:US
Mailing Address - Phone:248-798-7495
Mailing Address - Fax:
Practice Address - Street 1:28304 PIERCE ST
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-7312
Practice Address - Country:US
Practice Address - Phone:248-798-7495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other