Healthcare Provider Details

I. General information

NPI: 1912233370
Provider Name (Legal Business Name): JENNIE P MARTIN LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2009
Last Update Date: 10/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 SPRING ST
SPRINGDALE AR
72764-4567
US

IV. Provider business mailing address

257 PINE MEADOW DR
FARMINGTON AR
72730-8624
US

V. Phone/Fax

Practice location:
  • Phone: 479-751-5704
  • Fax: 479-750-7050
Mailing address:
  • Phone: 479-267-0268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberA0810076
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: