Provider Demographics
NPI:1316570781
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 1:22431 ANTONIO PKWY STE B160-493
Mailing Address - Street 2:
Mailing Address - City:RSM
Mailing Address - State:CA
Mailing Address - Zip Code:92688-2804
Mailing Address - Country:US
Mailing Address - Phone:949-528-5400
Mailing Address - Fax:
Practice Address - Street 1:29811 SANTA MARGARITA PKWY
Practice Address - Street 2:
Practice Address - City:RANCHO SANTA MARGARITA
Practice Address - State:CA
Practice Address - Zip Code:92688-3612
Practice Address - Country:US
Practice Address - Phone:949-600-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA297749225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist