Provider Demographics
NPI:1326818626
Name:REAVES, JEFFREY CARROL (PTA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:CARROL
Last Name:REAVES
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24139 HIBISCUS LN
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92532-2716
Mailing Address - Country:US
Mailing Address - Phone:731-420-3969
Mailing Address - Fax:
Practice Address - Street 1:23001 DEL LAGO DR
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1354
Practice Address - Country:US
Practice Address - Phone:949-387-7333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52945225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant