Basic Information
Provider Information
NPI: 1003295239
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MARTIN
FirstName: JENNIFER
MiddleName: LEE
NamePrefix:  
NameSuffix:  
Credential: D.O.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 751461
Address2:  
City: CHARLESTON
State: SC
PostalCode: 294253230
CountryCode: US
TelephoneNumber: 8437926200
FaxNumber:  
Practice Location
Address1: 171 ASHLEY AVE
Address2:  
City: CHARLESTON
State: SC
PostalCode: 294253230
CountryCode: US
TelephoneNumber: 8437921414
FaxNumber:  
Other Information
ProviderEnumerationDate: 05/20/2015
LastUpdateDate: 11/24/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 11/24/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000XOT016512PAN Allopathic & Osteopathic PhysiciansInternal Medicine 
2085R0202X39092SCY Allopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology

No ID Information.


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