Provider Demographics
NPI:1477102747
Name:MARTINEZ-JACOME, CRYSTAL (RN)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:
Last Name:MARTINEZ-JACOME
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:MOLDOVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1258
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44648-1258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:761 15TH ST SE
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-8256
Practice Address - Country:US
Practice Address - Phone:330-245-6443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-09
Last Update Date:2022-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.171745.MEDS-IV164W00000X
OHRN.510218163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty