Healthcare Provider Details

I. General information

NPI: 1841836541
Provider Name (Legal Business Name): JESSICA NICHOLE MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2019
Last Update Date: 11/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 S HILL ST
MOORELAND OK
73852-9015
US

IV. Provider business mailing address

320 S HILL ST
MOORELAND OK
73852-9015
US

V. Phone/Fax

Practice location:
  • Phone: 580-334-7010
  • Fax:
Mailing address:
  • Phone: 580-334-7010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: