Provider Demographics
NPI:1821443748
Name:MARTIN, JAKE MICHAEL
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:MICHAEL
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6102 AVENIDA ENCINAS
Mailing Address - Street 2:STE E
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92011-1005
Mailing Address - Country:US
Mailing Address - Phone:760-692-5142
Mailing Address - Fax:760-634-9752
Practice Address - Street 1:700 GARDEN VIEW CT STE 103
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-2478
Practice Address - Country:US
Practice Address - Phone:760-632-6942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-28
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic