Provider Demographics
NPI:1629166343
Name:MARTIN, JEFFREY PAUL (DC)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:PAUL
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 SOUTH PLEASANT STREET
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356-1953
Mailing Address - Country:US
Mailing Address - Phone:815-875-3661
Mailing Address - Fax:815-875-1925
Practice Address - Street 1:516 SOUTH PLEASANT STREET
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356-1953
Practice Address - Country:US
Practice Address - Phone:815-875-3661
Practice Address - Fax:815-875-1925
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038004206111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL615601OtherBLUE CROSS BLUE SHIELD
IL615601Medicaid
T37978Medicare UPIN
IL615601Medicaid