Provider Demographics
NPI:1487136172
Name:MARTIN, JACQULYN LORAINE (PTA)
Entity type:Individual
Prefix:
First Name:JACQULYN
Middle Name:LORAINE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MS
Other - First Name:JACQULYN
Other - Middle Name:LORAINE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:37 TWO PINES LN
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624-5861
Mailing Address - Country:US
Mailing Address - Phone:830-998-9972
Mailing Address - Fax:
Practice Address - Street 1:1400 HILLTOP RD
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-2851
Practice Address - Country:US
Practice Address - Phone:830-895-3200
Practice Address - Fax:830-895-3865
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2008652225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2008652OtherPROFESSIONAL LICENSE