Provider Demographics
NPI:1942421672
Name:MARTIN, JACQUELYN R (CNM)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:R
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:R
Other - Last Name:ROBINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2651 E DISCOVERY PKWY
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-9059
Practice Address - Country:US
Practice Address - Phone:812-918-3400
Practice Address - Fax:812-918-5829
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3015292363LW0102X
OHCOA 07946 NM367A00000X
IN09000415A367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH07946OtherOHIO LICENSE
IN300002078Medicaid
IN090540823OtherMEDICARE
OH0099346Medicaid