Healthcare Provider Details

I. General information

NPI: 1649533589
Provider Name (Legal Business Name): ADRINNIE M MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2012
Last Update Date: 06/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

917 WESTRIDGE
JACKSON MS
39209
US

IV. Provider business mailing address

PO BOX 266
JACKSON MS
39205-0266
US

V. Phone/Fax

Practice location:
  • Phone: 601-316-8686
  • Fax:
Mailing address:
  • Phone: 601-316-8686
  • Fax: 601-500-5743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: