Provider Demographics
NPI:1306180542
Name:MARTIN, JACQUELINE C (APRN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:C
Last Name:MARTIN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:C
Other - Last Name:ERCOLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:26 CHAMBERLAIN HWY
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06037-1921
Mailing Address - Country:US
Mailing Address - Phone:860-893-0040
Mailing Address - Fax:860-893-0046
Practice Address - Street 1:26 CHAMBERLAIN HWY
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:CT
Practice Address - Zip Code:06037-1921
Practice Address - Country:US
Practice Address - Phone:860-893-0040
Practice Address - Fax:860-893-0046
Is Sole Proprietor?:No
Enumeration Date:2012-11-10
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005215363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008042980Medicaid