Provider Demographics
NPI:1366807778
Name:MARTIN, JAMITA
Entity type:Individual
Prefix:
First Name:JAMITA
Middle Name:
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:PO BOX 2298
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-0005
Mailing Address - Country:US
Mailing Address - Phone:770-634-9994
Mailing Address - Fax:855-413-6890
Practice Address - Street 1:6468 HWY 92
Practice Address - Street 2:SUITE 140
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30102-0005
Practice Address - Country:US
Practice Address - Phone:770-634-9994
Practice Address - Fax:855-413-6890
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALC20150000857320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities