Provider Demographics
NPI:1023072188
Name:MARTIN, JENNIFER A (DPT, OCS, FAAOMPT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:F
Credentials:DPT, OCS, FAAOMPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 HOMESTEAD DR APT 38
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-8162
Mailing Address - Country:US
Mailing Address - Phone:612-339-2041
Mailing Address - Fax:970-476-7511
Practice Address - Street 1:1295 WESTHAVEN DR
Practice Address - Street 2:
Practice Address - City:VAIL
Practice Address - State:CO
Practice Address - Zip Code:81657-4395
Practice Address - Country:US
Practice Address - Phone:970-476-7510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5264225100000X
CO00048382251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN060T1MAOtherBC INDIV PROV ID
MN076649600Medicaid
MN6402269OtherMEDICA INDIV PROV ID