MEDICARE: JACLYN MARTIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	051.291094	IL

General Provider Information

NPI Number	:	1114327376
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACLYN MARTIS

Provider Business Mailing Address
First Line	:	1420 LAWRENCE AVE
Second Line	:
City	:	LOCKPORT
State	:	IL
Zip	:	60441-4202
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1420 LAWRENCE AVE
Second Line	:
City	:	LOCKPORT
State	:	IL
Zip	:	60441-4202
Country	:	US
Telephone Number	:	815-834-9058
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2014
Last Update Date	:	08/25/2014

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Directions to “ JACLYN MARTIS ” Practice Location

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