Provider Demographics
NPI:1932381654
Name:MARTIN LANE, JENNIFER JO (OD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JO
Last Name:MARTIN LANE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E SHEPARDSON ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:KY
Mailing Address - Zip Code:42445-1633
Mailing Address - Country:US
Mailing Address - Phone:270-365-6627
Mailing Address - Fax:931-645-0348
Practice Address - Street 1:1111A FORT CAMPBELL BLVD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-6426
Practice Address - Country:US
Practice Address - Phone:931-645-0346
Practice Address - Fax:931-645-0348
Is Sole Proprietor?:No
Enumeration Date:2007-12-04
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3098-035152W00000X
KY1631DT152W00000X
TN3423152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ032337Medicaid
KY77001501Medicaid