Healthcare Provider Details

I. General information

NPI: 1881332708
Provider Name (Legal Business Name): JENNIFER MAE MARTIN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2022
Last Update Date: 05/20/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 CHURCH ST
LEBANON PA
17046-4656
US

IV. Provider business mailing address

809 S 14TH AVE
LEBANON PA
17042-8840
US

V. Phone/Fax

Practice location:
  • Phone: 717-272-2700
  • Fax:
Mailing address:
  • Phone: 717-701-1582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP02284
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP022284
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: