Healthcare Provider Details

I. General information

NPI: 1487927752
Provider Name (Legal Business Name): JACKIE LYNN MARTIN OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2012
Last Update Date: 02/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 KILGORE DR
ASHLAND KY
41101-3118
US

IV. Provider business mailing address

5052 MAID MARION CT
ASHLAND KY
41101-6822
US

V. Phone/Fax

Practice location:
  • Phone: 606-831-8752
  • Fax:
Mailing address:
  • Phone: 606-831-8752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberR1895
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code225XL0004X
TaxonomyLow Vision Occupational Therapist
License NumberR1895
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License NumberR1895
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License NumberR1895
License Number StateKY
# 5
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberR1895
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: