Basic Information
Provider Information | |||||||||
NPI: | 1114032018 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARTIN | ||||||||
FirstName: | JACOB | ||||||||
MiddleName: | LEE | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4700 SETON CENTER PKWY | ||||||||
Address2: | STE 200 | ||||||||
City: | AUSTIN | ||||||||
State: | TX | ||||||||
PostalCode: | 787594107 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5124391000 | ||||||||
FaxNumber: | 5124391081 | ||||||||
Practice Location | |||||||||
Address1: | 4700 SETON CENTER PKWY | ||||||||
Address2: | STE 200 | ||||||||
City: | AUSTIN | ||||||||
State: | TX | ||||||||
PostalCode: | 787594107 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5124391000 | ||||||||
FaxNumber: | 5124391081 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/20/2006 | ||||||||
LastUpdateDate: | 11/20/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1161218 | TX | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 742862345 | 01 | TX | GOLDEN RULE | OTHER | 772862345 | 01 | TX | GREAT WEST | OTHER | 742862345 | 01 | TX | SCOTT & WHITE | OTHER | 2274981 | 01 | TX | FIRST HEALTH | OTHER | 742862345 | 01 | TX | HEALTHSMART | OTHER | 742862345 | 01 | TX | GALAXY | OTHER | 742862345 | 01 | TX | PHCS | OTHER | 742862345 | 01 | TX | TRUE CHOICE | OTHER | 742862345 | 01 | TX | HUMANA | OTHER | 742862345 | 01 | TX | UNICARE | OTHER | 8T4542/0092EX | 01 | TX | BCBS | OTHER | 742862345 | 01 | TX | CIGNA | OTHER |