Provider Demographics
NPI:1982623203
Name:MARTIN, JESSICA LYNNE (PA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNNE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 RIDGEWAY AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4127
Mailing Address - Country:US
Mailing Address - Phone:585-922-2440
Mailing Address - Fax:585-663-3293
Practice Address - Street 1:2350 RIDGEWAY AVE
Practice Address - Street 2:SUITE A
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4127
Practice Address - Country:US
Practice Address - Phone:585-922-2440
Practice Address - Fax:585-663-3293
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010137363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPA0512OtherPREFERRED CARE
NYPO19010137OtherBLUE CHOICE
NYPA0512OtherPREFERRED CARE OPT
NYPO19010137OtherBLUE CROSS OF ROCHESTER
NY010137Medicaid
NYPO19010137OtherBLUE CHOICE OPT
NYPA0512OtherPREFERRED CARE OPT