1023391794 NPI number — MS. MARTHA JENNINGS PT

Table of content: MS. MARTHA JENNINGS PT (NPI 1023391794)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023391794 NPI number — MS. MARTHA JENNINGS PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JENNINGS
Provider First Name:
MARTHA
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023391794
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
119 OAKVIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEXARKANA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75501-0963
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-334-7476
Provider Business Mailing Address Fax Number:
870-774-4790

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4824 MCKNIGHT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEXARKANA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75503-0935
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-793-6135
Provider Business Practice Location Address Fax Number:
903-793-0053
Provider Enumeration Date:
09/20/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1140978 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1140978 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 195157721 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 288237501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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