Provider Demographics
NPI:1427206028
Name:MARTIN, JENNIFER (COTA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10371 REDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-8783
Mailing Address - Country:US
Mailing Address - Phone:847-345-4336
Mailing Address - Fax:
Practice Address - Street 1:6685 E 117TH AVE
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-7808
Practice Address - Country:US
Practice Address - Phone:219-663-6392
Practice Address - Fax:219-663-3529
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001382A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant