Healthcare Provider Details

I. General information

NPI: 1942784806
Provider Name (Legal Business Name): JARED TRAVIS MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2018
Last Update Date: 09/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 E BROADWAY AVE
JACKSON WY
83001-8642
US

IV. Provider business mailing address

16710 VIA LOS CABALLEROS
RIVERSIDE CA
92504-6172
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-3636
  • Fax:
Mailing address:
  • Phone: 951-591-1516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number0917
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2122305
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: