Provider Demographics
NPI:1639507551
Name:MARTIN, JASON (PMHNP-BC)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13734 S 1ST E
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7852
Mailing Address - Country:US
Mailing Address - Phone:208-360-0288
Mailing Address - Fax:
Practice Address - Street 1:13734 S 1ST E
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7852
Practice Address - Country:US
Practice Address - Phone:208-360-0288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-31
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-RN-LIC-39018363LP0808X
IDNP 1389A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health