Basic Information
| Provider Information | |||||||||
| NPI: | 1770805376 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 403 34TH AVE E | ||||||||
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| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354043327 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 245 CAHABA VALLEY PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | PELHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351242217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059426820 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2010 | ||||||||
| LastUpdateDate: | 02/23/2010 | ||||||||
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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 | 225X00000X | 3127 | AL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.