Provider Demographics
NPI:1053008409
Name:MARTIN, JACOB RYAN
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:RYAN
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 DUNBAR PLZ
Mailing Address - Street 2:
Mailing Address - City:DUNBAR
Mailing Address - State:WV
Mailing Address - Zip Code:25064-3038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 DUNBAR PLZ
Practice Address - Street 2:
Practice Address - City:DUNBAR
Practice Address - State:WV
Practice Address - Zip Code:25064-3038
Practice Address - Country:US
Practice Address - Phone:304-513-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral