Provider Demographics
NPI:1881001170
Name:MARTIN, JESSE (ATC)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2463 AUGUSTA HWY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-2215
Mailing Address - Country:US
Mailing Address - Phone:803-821-3438
Mailing Address - Fax:
Practice Address - Street 1:2463 AUGUSTA HWY
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-2215
Practice Address - Country:US
Practice Address - Phone:803-821-3438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-18
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14322255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer