Provider Demographics
NPI:1891264982
Name:MARTIN, JESSICA A (PA)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5266 SGT LYTLE AVE UNIT A
Mailing Address - Street 2:
Mailing Address - City:FORT BLISS
Mailing Address - State:TX
Mailing Address - Zip Code:79906-3272
Mailing Address - Country:US
Mailing Address - Phone:713-732-7989
Mailing Address - Fax:
Practice Address - Street 1:5005 N. PIEDRAS ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79920
Practice Address - Country:US
Practice Address - Phone:915-742-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1158120363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant