Provider Demographics
NPI:1841417482
Name:MARTIN, JENNIFER GRAY (ND, LAC)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:GRAY
Last Name:MARTIN
Suffix:
Gender:F
Credentials:ND, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2104 MYRTLE PL SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-3143
Mailing Address - Country:US
Mailing Address - Phone:360-789-2977
Mailing Address - Fax:360-754-7255
Practice Address - Street 1:1324 HARRISON AVE NW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-5349
Practice Address - Country:US
Practice Address - Phone:360-754-7775
Practice Address - Fax:360-754-7255
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC00002102171100000X
WANT00001146175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered171100000XOther Service ProvidersAcupuncturist
Not Answered175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAC00002102OtherACUPUNCTURIST
WANT00001146OtherNATUROPATHIC PHYSICIAN