Provider Demographics
NPI:1245576313
Name:MARTIN, JARED WAYNE
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:WAYNE
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 1:3900 W CHARLESTON BLVD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3900 W CHARLESTON BLVD
Practice Address - Street 2:SUITE 170
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1628
Practice Address - Country:US
Practice Address - Phone:702-453-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-18
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker