Provider Demographics
NPI:1992911705
Name:MARTIN, JENNIFER LYN (PT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8812 EDMONSTON RD
Mailing Address - Street 2:
Mailing Address - City:BERWYN HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20740-2334
Mailing Address - Country:US
Mailing Address - Phone:301-982-9504
Mailing Address - Fax:301-982-9506
Practice Address - Street 1:5454 WISCONSIN AVE
Practice Address - Street 2:18TH FLOOR
Practice Address - City:CHEVY CHASE
Practice Address - State:MD
Practice Address - Zip Code:20815-6901
Practice Address - Country:US
Practice Address - Phone:240-350-6318
Practice Address - Fax:301-982-9506
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18241225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
H940-0001OtherCAREFIRST BCBS
J265JLOtherCAREFIRST BCBS