Healthcare Provider Details

I. General information

NPI: 1831900166
Provider Name (Legal Business Name): JEREMY DEAN MARTINELLI AGCNS-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2025
Last Update Date: 08/01/2025
Certification Date: 08/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 COLLEGE ST STE C
BASTROP TX
78602-3948
US

IV. Provider business mailing address

101 W LOUIS HENNA BLVD STE 300
AUSTIN TX
78728-1203
US

V. Phone/Fax

Practice location:
  • Phone: 512-244-4272
  • Fax: 512-244-2895
Mailing address:
  • Phone: 512-244-4272
  • Fax: 512-244-2895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License Number1123440
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: