Provider Demographics
NPI:1871791814
Name:MARTIN, JAN ELAINE (RD,LD,CDE)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:ELAINE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RD,LD,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5619 BLENDONRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43230-9847
Mailing Address - Country:US
Mailing Address - Phone:614-906-1875
Mailing Address - Fax:
Practice Address - Street 1:5619 BLENDONRIDGE DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43230-9847
Practice Address - Country:US
Practice Address - Phone:614-906-1875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1395133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered