MEDICARE: JACOB MARTIN

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1477288967
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB MARTIN

Provider Business Mailing Address
First Line	:	4501 N CAMINO DEL OBISPO
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85718-6605
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	445 E GLENHURST DR
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85704-6631
Country	:	US
Telephone Number	:	520-591-9196
Fax Number	:

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

Provider Enumeration Date	:	07/19/2022
Last Update Date	:	07/19/2022

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Directions to “ JACOB MARTIN ” Practice Location

Language	Start Address	Practice Location

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