Healthcare Provider Details

I. General information

NPI: 1598680779
Provider Name (Legal Business Name): JENNIFER MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N LIBERTY ST
BOISE ID
83704-8704
US

IV. Provider business mailing address

23887 TYLER LN
MIDDLETON ID
83644-5658
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-4063
  • Fax:
Mailing address:
  • Phone: 661-618-6934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number69851
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: