Healthcare Provider Details

I. General information

NPI: 1326321068
Provider Name (Legal Business Name): JEFF MARTINEZ MAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2011
Last Update Date: 09/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

137 MULLHERRIN DR
MADISON MS
39110-4534
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-6519
  • Fax: 601-815-3027
Mailing address:
  • Phone: 601-984-6519
  • Fax: 601-815-0327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT0318
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: