Healthcare Provider Details

I. General information

NPI: 1346529831
Provider Name (Legal Business Name): MARTINA A. JACKSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2011
Last Update Date: 08/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N BURHANS BLVD
HAGERSTOWN MD
21740-4677
US

IV. Provider business mailing address

201 N BURHANS BLVD
HAGERSTOWN MD
21740-4677
US

V. Phone/Fax

Practice location:
  • Phone: 301-791-2660
  • Fax: 301-791-5032
Mailing address:
  • Phone: 301-791-2660
  • Fax: 301-791-5032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR083446
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: