Healthcare Provider Details

I. General information

NPI: 1598699688
Provider Name (Legal Business Name): DESTIN JAMALL MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2285 CREEK VIEW PL
GROVE CITY OH
43123-4507
US

IV. Provider business mailing address

2285 CREEK VIEW PL
GROVE CITY OH
43123-4507
US

V. Phone/Fax

Practice location:
  • Phone: 567-202-5530
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.0042405
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: