Provider Demographics
NPI:1871290999
Name:MARTIN, JACQUELYN RUTH
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:RUTH
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 W WASHBOURNE ST
Mailing Address - Street 2:
Mailing Address - City:JAY
Mailing Address - State:OK
Mailing Address - Zip Code:74346-4205
Mailing Address - Country:US
Mailing Address - Phone:918-418-9625
Mailing Address - Fax:
Practice Address - Street 1:1015 W WASHBOURNE ST
Practice Address - Street 2:
Practice Address - City:JAY
Practice Address - State:OK
Practice Address - Zip Code:74346-4205
Practice Address - Country:US
Practice Address - Phone:918-418-9625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist