Healthcare Provider Details

I. General information

NPI: 1083173488
Provider Name (Legal Business Name): JASON A. MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2019
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2006 DECHERD BLVD
DECHERD TN
37324-3818
US

IV. Provider business mailing address

PO BOX 1258
WAYNESBORO TN
38485-1258
US

V. Phone/Fax

Practice location:
  • Phone: 931-967-7171
  • Fax:
Mailing address:
  • Phone: 931-253-1110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number25475
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: