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General NPI Number Information
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NPI Number | 1942803499
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Entity Type | Individual
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Provider Name | JATESSA JATE LINN MARTIN
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Gender | Female
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Dates
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Enumeration Date | 11/18/2020
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Last Update Date | 11/18/2020
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Provider Practice Location Address
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Address Line | 2029 5TH AVE S
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City | FORT DODGE
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State | IA
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Zip | 50501-4307
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Country | US
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Telephone | 515-955-6453
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Fax |
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Provider Business Mailing Address
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Address Line | 1352 N 14TH ST
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City | FORT DODGE
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State | IA
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Zip | 50501-7532
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Country | US
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Telephone | 712-369-0015
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 22862
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License Number State | IA
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