Healthcare Provider Details

I. General information

NPI: 1114208089
Provider Name (Legal Business Name): JACQUELINE E MARTIN MS, RD, CDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2011
Last Update Date: 09/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 AVENUE LOUISE
MASSAPEQUA PARK NY
11762-3207
US

IV. Provider business mailing address

13 AVENUE LOUISE
MASSAPEQUA PARK NY
11762-3207
US

V. Phone/Fax

Practice location:
  • Phone: 516-236-3984
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number006357
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: