Provider Demographics
NPI:1508860420
Name:MARTIN, JEANNE R (PAC)
Entity Type:Individual
Prefix:MRS
First Name:JEANNE
Middle Name:R
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1132
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29802-1132
Mailing Address - Country:US
Mailing Address - Phone:803-648-3130
Mailing Address - Fax:803-648-9860
Practice Address - Street 1:526 RICHLAND AVE W
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-3828
Practice Address - Country:US
Practice Address - Phone:803-648-3130
Practice Address - Fax:803-648-9860
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC423363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQM0345Medicaid
SCQ31434Medicare UPIN