Provider Demographics
NPI:1942803499
Name:MARTIN, JATESSA JATE LINN
Entity Type:Individual
Prefix:
First Name:JATESSA
Middle Name:JATE LINN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1352 N 14TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-7532
Mailing Address - Country:US
Mailing Address - Phone:712-369-0015
Mailing Address - Fax:
Practice Address - Street 1:2029 5TH AVE S
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-4307
Practice Address - Country:US
Practice Address - Phone:515-955-6453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22862183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist