Provider Demographics
NPI:1639482540
Name:MARTIN, JESSICA ANNE (MSOT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MSOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1377 11TH ST NW
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732-5068
Mailing Address - Country:US
Mailing Address - Phone:563-241-4230
Mailing Address - Fax:563-519-4235
Practice Address - Street 1:1377 11TH ST NW
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-5068
Practice Address - Country:US
Practice Address - Phone:563-241-4230
Practice Address - Fax:563-519-4235
Is Sole Proprietor?:No
Enumeration Date:2010-07-20
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002029225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist