Provider Demographics
NPI:1912233370
Name:MARTIN, JENNIE P (LAC)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:P
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:257 PINE MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:AR
Mailing Address - Zip Code:72730-8624
Mailing Address - Country:US
Mailing Address - Phone:479-267-0268
Mailing Address - Fax:
Practice Address - Street 1:130 SPRING ST
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-4567
Practice Address - Country:US
Practice Address - Phone:479-751-5704
Practice Address - Fax:479-750-7050
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-20
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA0810076172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker