Provider Demographics
NPI:1629149406
Name:MARTIN, JESSICA GAIL (RPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:GAIL
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:GAIL
Other - Last Name:LOFLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPT
Mailing Address - Street 1:PO BOX 426
Mailing Address - Street 2:
Mailing Address - City:MAGEE
Mailing Address - State:MS
Mailing Address - Zip Code:39111-0426
Mailing Address - Country:US
Mailing Address - Phone:601-849-6440
Mailing Address - Fax:601-849-7557
Practice Address - Street 1:813 W THIRD ST
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:MS
Practice Address - Zip Code:39074-4006
Practice Address - Country:US
Practice Address - Phone:601-469-1001
Practice Address - Fax:601-469-1009
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3789225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06584588Medicaid