Healthcare Provider Details

I. General information

NPI: 1023072188
Provider Name (Legal Business Name): JENNIFER A MARTIN DPT, OCS, FAAOMPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 04/13/2020
Certification Date: 04/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1295 WESTHAVEN DR
VAIL CO
81657-4395
US

IV. Provider business mailing address

570 HOMESTEAD DR APT 38
EDWARDS CO
81632-8162
US

V. Phone/Fax

Practice location:
  • Phone: 970-476-7510
  • Fax:
Mailing address:
  • Phone: 612-339-2041
  • Fax: 970-476-7511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5264
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number0004838
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: