Provider Demographics
NPI:1659434876
Name:MARTIN, JACQUELYN HAIRSTON (C-FNP)
Entity type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:HAIRSTON
Last Name:MARTIN
Suffix:
Gender:F
Credentials:C-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2746 DODSON LEE DR
Mailing Address - Street 2:
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-3960
Mailing Address - Country:US
Mailing Address - Phone:404-346-1330
Mailing Address - Fax:
Practice Address - Street 1:107 UPPER RIVERDALE RD SW
Practice Address - Street 2:SUITE B
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2540
Practice Address - Country:US
Practice Address - Phone:770-692-2800
Practice Address - Fax:770-692-2804
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN052052363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily