| Doctor Name: | MRS. JACQUELINE WILSON MARTIN |
| NPI Number: | 1073667226 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | FCL-079-037 |
| Business Practice Address: | 538 Warriner St Reidsville, NC - 273203053 |
| Business Phone Number: | 3363486902 |
| Business Fax Number: | |
| Mailing Address: | 210 S Van Buren Rd, EDEN |
| State: | NC |
| Postal Code: | 272885025 |
| Phone Number: | 3365772173 |
| Fax Number: | 3365891320 |
| NPI Enumeration Date: | 01/23/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 177F00000X |
| License Number: | FCL-079-037 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NC |
| Taxonomy Type: | Other Service Providers |
| Taxonomy Classification: | Lodging |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A public or privately owned facility providing overnight lodging to individuals traveling long distances or receiving prolonged outpatient medical services away from home. |