Provider Demographics
NPI:1902405012
Name:MARTIN, TIFFANY JASMINE
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:JASMINE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:JASMINE
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15911 JUDSON DR
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-2153
Mailing Address - Country:US
Mailing Address - Phone:216-704-7692
Mailing Address - Fax:
Practice Address - Street 1:2000 AUBURN DR
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-4314
Practice Address - Country:US
Practice Address - Phone:216-704-7692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-20
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN0014229703376K00000X
OH501053941205376K00000X
251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No376K00000XNursing Service Related ProvidersNurse's Aide