Provider Demographics
NPI:1902143167
Name:MARTIN, JEANINE (LAC)
Entity type:Individual
Prefix:
First Name:JEANINE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 BARSTOW RD STE 302
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-2209
Mailing Address - Country:US
Mailing Address - Phone:516-288-5333
Mailing Address - Fax:
Practice Address - Street 1:29 BARSTOW RD STE 302
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-2209
Practice Address - Country:US
Practice Address - Phone:516-288-5333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-08
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004659171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY004659OtherLICENSE
NY1924773OtherREGISTRATION CERTIFICATE
NY1902143167OtherNPI