Basic Information
| Provider Information | |||||||||
| NPI: | 1043857840 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RDN, LDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 311 NORTH ST | ||||||||
| Address2: | |||||||||
| City: | WEST PITTSTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 186432127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704668319 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1111 E END BLVD | ||||||||
| Address2: | |||||||||
| City: | WILKES BARRE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187110030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708243521 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2019 | ||||||||
| LastUpdateDate: | 11/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DN006948 | PA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | - | 01 | - | OTHER |