Provider Demographics
NPI:1518637479
Name:MARTIN, JONATHAN TAYLOR (MAE)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:TAYLOR
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MAE
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 694
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:WV
Mailing Address - Zip Code:26260-0694
Mailing Address - Country:US
Mailing Address - Phone:304-694-5226
Mailing Address - Fax:
Practice Address - Street 1:812 THOMAS AVE
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:WV
Practice Address - Zip Code:26260-0694
Practice Address - Country:US
Practice Address - Phone:304-694-5226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker