Provider Demographics
NPI:1609562727
Name:MARTIN, JODI LYNN
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:LYNN
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 1:1845 ALTGELD ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-1603
Mailing Address - Country:US
Mailing Address - Phone:317-512-6929
Mailing Address - Fax:
Practice Address - Street 1:1540 TRINITY PL
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-5006
Practice Address - Country:US
Practice Address - Phone:574-272-9000
Practice Address - Fax:574-272-9290
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN27058896A164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty