Provider Demographics
NPI:1245738244
Name:MARTIN, JASON LLOYD (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:LLOYD
Last Name:MARTIN
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HOSPITAL ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-3354
Mailing Address - Country:US
Mailing Address - Phone:662-554-2322
Mailing Address - Fax:
Practice Address - Street 1:2601 GETWELL RD STE 1
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-6762
Practice Address - Country:US
Practice Address - Phone:662-287-7138
Practice Address - Fax:662-287-7157
Is Sole Proprietor?:No
Enumeration Date:2018-01-25
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902498363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09136238Medicaid