Provider Demographics
NPI:1629407580
Name:MARTIN, JESSICA (MT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 W SHADBOLT ST
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48362-3170
Mailing Address - Country:US
Mailing Address - Phone:248-287-2072
Mailing Address - Fax:
Practice Address - Street 1:24 W SHADBOLT ST
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48362-3170
Practice Address - Country:US
Practice Address - Phone:248-287-2072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-01
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI578640-09225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist