Provider Demographics
NPI:1790678290
Name:MARTIN, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MARTIN
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2217 H ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBURY
Mailing Address - State:NE
Mailing Address - Zip Code:68352-1118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1105 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-3739
Practice Address - Country:US
Practice Address - Phone:785-532-6544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-02
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program