Provider Demographics
NPI:1659860724
Name:MARTIN, JARED JOHN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:JOHN
Last Name:MARTIN
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22874 NORTHWOODS DR
Mailing Address - Street 2:
Mailing Address - City:CHUGIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99567-5460
Mailing Address - Country:US
Mailing Address - Phone:208-680-0499
Mailing Address - Fax:
Practice Address - Street 1:258 S ALASKA ST
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-6334
Practice Address - Country:US
Practice Address - Phone:907-746-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-04
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID58454363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily