Provider Demographics
NPI:1174305007
Name:MARTIN, ERICA NICOLE
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:NICOLE
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 1:364 N PARKWAY STE 8
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2874
Mailing Address - Country:US
Mailing Address - Phone:731-736-1005
Mailing Address - Fax:731-736-1111
Practice Address - Street 1:364 N PARKWAY STE 8
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2874
Practice Address - Country:US
Practice Address - Phone:731-431-7241
Practice Address - Fax:731-736-1111
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-16
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNI000000022582320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ087092Medicaid