Provider Demographics
NPI:1235483462
Name:MARTIN, JERRICO LAMON
Entity Type:Individual
Prefix:MR
First Name:JERRICO
Middle Name:LAMON
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6726 E 26TH CT
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74129-6206
Mailing Address - Country:US
Mailing Address - Phone:918-406-7716
Mailing Address - Fax:
Practice Address - Street 1:6726 E 26TH CT
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74129-6206
Practice Address - Country:US
Practice Address - Phone:918-406-7716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-09
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator