Provider Demographics
NPI:1558095828
Name:MARTIN, JENNIFER LEIGH
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEIGH
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 1:3450 VALLEY PLAZA PKWY
Mailing Address - Street 2:
Mailing Address - City:FT WRIGHT
Mailing Address - State:KY
Mailing Address - Zip Code:41017-8177
Mailing Address - Country:US
Mailing Address - Phone:859-341-3767
Mailing Address - Fax:859-341-3789
Practice Address - Street 1:3450 VALLEY PLAZA PKWY
Practice Address - Street 2:
Practice Address - City:FT WRIGHT
Practice Address - State:KY
Practice Address - Zip Code:41017-8177
Practice Address - Country:US
Practice Address - Phone:859-341-3767
Practice Address - Fax:859-341-3789
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY268337156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician