Healthcare Provider Details

I. General information

NPI: 1902405012
Provider Name (Legal Business Name): TIFFANY JASMINE MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TIFFANY JASMINE WOOD

II. Dates (important events)

Enumeration Date: 10/20/2020
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 AUBURN DR
BEACHWOOD OH
44122-4314
US

IV. Provider business mailing address

15911 JUDSON DR
CLEVELAND OH
44128-2153
US

V. Phone/Fax

Practice location:
  • Phone: 216-704-7692
  • Fax:
Mailing address:
  • Phone: 216-704-7692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberCN0014229703
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number501053941205
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: