Provider Demographics
NPI:1477194157
Name:MARTIN, JORDYN A
Entity Type:Individual
Prefix:
First Name:JORDYN
Middle Name:A
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 1:66 LUSSCROFT RD.
Mailing Address - Street 2:
Mailing Address - City:WANTAGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07461
Mailing Address - Country:US
Mailing Address - Phone:862-266-6570
Mailing Address - Fax:
Practice Address - Street 1:66 LUSSCROFT RD.
Practice Address - Street 2:
Practice Address - City:WANATGE
Practice Address - State:NJ
Practice Address - Zip Code:07461
Practice Address - Country:US
Practice Address - Phone:862-266-6570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer