Provider Demographics
NPI:1508476581
Name:REESE, JARVIS
Entity Type:Individual
Prefix:
First Name:JARVIS
Middle Name:
Last Name:REESE
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 1:413 TUG CT
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-2134
Mailing Address - Country:US
Mailing Address - Phone:478-718-3504
Mailing Address - Fax:
Practice Address - Street 1:775 POPLAR RD STE 130
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-8307
Practice Address - Country:US
Practice Address - Phone:770-683-6291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN259527363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care