Provider Demographics
NPI:1245668342
Name:MARTIN, JEANNIE RENEE (LMT)
Entity type:Individual
Prefix:
First Name:JEANNIE
Middle Name:RENEE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7524 BOSQUE BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-3779
Mailing Address - Country:US
Mailing Address - Phone:254-315-5651
Mailing Address - Fax:
Practice Address - Street 1:7524 BOSQUE BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-3779
Practice Address - Country:US
Practice Address - Phone:254-315-5651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT114600225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist