Provider Demographics
NPI:1942064944
Name:MARTIN, JACK
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SOFIA
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:723 HOMESTEAD AVE
Mailing Address - Street 2:
Mailing Address - City:SCOTTDALE
Mailing Address - State:PA
Mailing Address - Zip Code:15683-2703
Mailing Address - Country:US
Mailing Address - Phone:724-244-2696
Mailing Address - Fax:
Practice Address - Street 1:5241 LIBERTY AVE STE 10B
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15224-2387
Practice Address - Country:US
Practice Address - Phone:412-346-6088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-09
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist