Basic Information
| Provider Information | |||||||||
| NPI: | 1942784806 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | JARED | ||||||||
| MiddleName: | TRAVIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16710 VIA LOS CABALLEROS | ||||||||
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| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925046172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9515911516 | ||||||||
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| Practice Location | |||||||||
| Address1: | 625 E BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 830018642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077333636 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2018 | ||||||||
| LastUpdateDate: | 09/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 0917 | WY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225200000X | 2122305 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.